印度南德里儿童肺结核患者在dots策略下的治疗转归

地点:印度新德里结核病研究所儿童肺病科.目的:评价儿童肺结核患者在dots策略下的治疗转归.设计:对1 098例儿童肺结核患者的资料进行回顾性分析.结果:在本研究中,儿童肺结核患者的平均年龄11.2岁,女性(61.7%)多于男性(38.3 %).0～5、6～10和11～14岁年龄组病人分别占18.3%、26.6 %和55.1%.病人的登记分类包括:新病人(87.7 %)、复发(1.9%)、失败(1.0%)、丢失返回(5.0%)、迁入(0.9%)和其他(3.5%).在全部患者中,痰涂片阳性者414例,阴性者404例,未痰检或检查结果不详者280例.痰涂片阳性率随年龄而增高.使用Ⅰ类、Ⅱ类和Ⅲ类治疗方案的患者分别占50.6%、10.5%和38.9%.新病人和复治病人的治愈率分别为92.4%(302/327)和92%(80/87)(x21=0.02,p=0.901).但新病人的治疗完成率(97%,636/656)明显高于复治病人(53.6 %,15/28)(x21=100.8,p＜0.001).新病人和复治病人的治疗成功率分别为95.4%和82.6%(x21=30.35,p＜0.001).总的说来,治疗转归为丢失、失败和死亡的患者比例分别占3%、1.9%和1%.结论:dots的确是高效的治疗管理策略.     

New cases of pulmonary tuberculosis treatment within DOTS strategy

Treatment outcomes were analyzed in 216 patients of whom 119 patients received the DOTS treatment, 97 had conventional therapy. No bacterial isolation was found in 88% of patients, decay cavities became closed in 61%. Due to the DOTS therapy, sputum conversion was achieved in 93% of cases, no Mycobacteria tuberculosis being found in 70.2% of cases after 2-month therapy. Decay cavities could not be identified in 80% by the end of chemotherapy.     

Predictors of relapse among pulmonary tuberculosis patients treated in a DOTS programme in South India.

OBJECTIVE: To identify risk factors associated with relapse among cured tuberculosis (TB) patients in a DOTS programme in South India. DESIGN: Sputum samples collected from a cohort of TB patients registered between April 2000 and December 2001 were examined by fluorescence microscopy for acid-fast bacilli and by culture for Mycobacterium tuberculosis at 6, 12 and 18 months after treatment completion. RESULTS: Of the 534 cured patients, 503 (94%) were followed up for 18 months after treatment completion. Of these, 62 (12%) relapsed during the 18-month period; 48 (77%) of the 62 relapses occurred during the first 6 months of follow-up. Patients who took treatment irregularly were twice more likely to have a relapse than adherent patients (20% vs. 9%; adjusted odds ratio [aOR] 2.5; 95% CI 1.4-4.6). Other independent predictors of relapse were initial drug resistance to isoniazid and/or rifampicin (aOR 4.8; 95% CI 2.0-11.6) and smoking (aOR 3.1; 95% CI 1.6-6.0). The relapse rate among non-smoking, treatment adherent patients with drug-sensitive organisms was 4.8%. CONCLUSIONS: The relapse rate under the DOTS programme may be reduced by ensuring that patients take their treatment regularly and are counselled effectively about quitting smoking.     

初治涂阳肺结核病人DOTS及非DOTS干预的成本-效果分析

目的 评价初治涂阳肺结核病人DOTS及非DOTS干预的成本 -效果?方法 以初治涂阳肺结核病人用于药品?痰涂片?痰培养及X线检查四个部分的支出构成成本 ;干预的效果包括直接与间接效果两部分 :一是治愈病人而减少的DALY损失 ,二是降低传染而减少的DALY损失?结果 DOTS干预的病人以 4.5 7元即可挽救一个寿命年 ,而非DOTS干预的病人则需要 4.71.3元才能挽救一个寿命年?结论 DOTS是费用 -效果佳的结核病控制策略?     

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.     

Prevalence of drug resistance under the DOTS strategy in Hyderabad, South India, 2001-2003.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB), defined as resistance to at least isoniazid (INH) and rifampicin (RMP), is considered a threat to TB control. Implementation of DOTS ensures high cure rates and prevents MDR. OBJECTIVE: To study the prevalence of MDR-TB from a retrospective analysis of the data in a tuberculosis unit where DOTS was implemented over a period of 6 years through public private mix (PPM). METHODS: Drug susceptibility testing of Mycobacterium tuberculosis samples isolated from the cultures of newly registered and retreatment sputum smear-positive cases during 2001-2003. RESULTS: During the study, 909 sputum-positive cases were registered and analysed. Of these, 714 were new and 195 were retreatment sputum-positive cases. INH resistance was found in 3.2% (23) of new and 9.2% (18) of retreatment cases. RMP resistance was present in 1.5% (11) of new and 7.2% (14) of retreatment cases. MDR was present only in 0.14% (1) of new and 2% (4) of retreatment cases. New cases had cure rates of 96% compared to 85% in retreatment cases. CONCLUSION: The prevalence of MDR-TB is low where success rates are high.     

The DOTS strategy for controlling the global tuberculosis epidemic

This article reviews the principles, scientific basis, and experience with implementation of the directly observed treatment strategy, short course (DOTS) for tuberculosis. The relevance of DOTS in the context of multidrug-resistant tuberculosis and the HIV epidemic also is discussed.     

老年肺结核督导化疗法在防治中的重要意义

在医务人员面视下短程化学疗法或督导化疗 (ｄｉｒｅｃｔｅｌｙｏｂｓｅｒｖｅｄｔｒｅａｔｍｅｎｔ,ｓｈｏｒｔ ｃｏｕｒｓｅ ,ＤＯＴＳ) ,是当今控制结核病问题的关键措施。我们从 1978年开始在北京市广泛推行ＤＯＴＳ ,通过 2 0余年实践 ,现将ＤＯＴＳ有关情况介绍如下。1　ＤＯＴＳ的优越性1 1　确保结核病人坚持合理规律地完成全疗程的化学疗法 ,初治肺结核化学疗法方案 ,如果病人坚持完成全疗程的规律治疗 ,几乎能达到百分之百的治愈 ,ＤＯＴＳ是保证规律用药的最好措施。推行ＤＯＴＳ后 ,北京市肺结核病人坚持规律用药率由原来的 4 0…     

The role of DOTS in tuberculosis treatment and control

Directly Observed Therapy Shortcourse (DOTS) is composed of five distinct elements: political commitment; microscopy services; drug supplies; surveillance and monitoring systems and use of highly efficacious regimens; and direct observation of treatment. The difference in the way the term 'DOTS' as defined by WHO and interpreted by many observers has led to some misunderstanding. WHO generally uses the term to mean the five components of DOTS. But the word 'DOTS' is an acronym for Directly Observed Therapy Shortcourse. Many workers therefore interpret DOTS purely as direct supervision of therapy. DOTS is not an end in itself but a means to an end. In fact it has two purposes, to ensure that the patient with tuberculosis (TB) completes therapy to cure and to prevent drug resistance from developing in the community. The main criticism of DOTS rightly derives from the fact that some properly conducted randomized, controlled trials of directly observed therapy with or without the other components have shown no benefit from it. The problem is that it is impossible to design a study of modern directly observed therapy against the previous self-administered, poorly-resourced programs. As soon as a study is implemented, the attention to patients in the control (non-directly observed therapy) arm inevitably improves from the previous non-trial service situation. What is of concern is that in some trials less than 70% cure rates were achieved even in the direct observation arm. With no new drugs or adjuvant treatment available to bring the length of treatment down to substantially less than 6 months, DOTS offers the best means we have at our disposal for TB control.     

Adherence to tuberculosis treatment: lessons from the urban setting of Delhi,India

The Revised National Tuberculosis Control Programme (RNTCP), which incorporated the WHO DOTS strategy was introduced in India in the mid-1990s. An operational research project was conducted between 1996 and 1998 to assess the needs and perspectives of patients and providers in two chest clinics in Delhi, Moti Nagar and Nehru Nagar, during the introduction of the new strategy. This paper reports on the findings of the project, concentrating on information collected from 40 in-depth interviews with patient defaulters and from non-participant observations in clinics and directly observed treatment centres. In Moti Nagar chest clinic, 117 of 1786 (6.5%) patients and 195 of 1890 (10%) patients in Nehru Nagar left care before their treatment was complete. It was argued that the reasons for default stem from a poor correlation between patient and programme needs and priorities, and from particular characteristics of the disease and its treatment. Patient needs that were not met by the health system included convenient clinic timings, arrangements for the provision for treatment in the event of a family emergency and provision for complicated cases like alcoholics. The problems facing the provider were poor interpersonal communication with the health staff, lack of attention and support at the clinic, difficulty for patients to re-enter the system if they missed treatment and, in certain areas, long distances to the clinic. Problems related to diseases were inability of the staff to deal with drug side-effects, and patients' conception of equating well-being with cure. Simple, practical measures could improve the provision of tuberculosis (TB) treatment: more flexible hours, allowances for poor patients to reach the clinics and training health care staff for respectful communication and monitoring drug side-effects. The findings indicate a need to rethink the label of 'defaulter' often given to the patients. The important areas for future operational research is also highlighted.     

To study the occurrence of risk factors for pulmonary tuberculosis in the homeless population in areas of Delhi,India

BackgroundIn India, there are only a few studies done in the area of assessing the risk factors of Tuberculosis (TB) among the homeless population. The homeless population has quite a higher chance of developing Pulmonary Tuberculosis (PTB) as compared with the general population due to the presence of an inappropriate environment and high prevalence of risk factors.MethodsThis study was done among the homeless population in both males and females aged 18 years and above in areas of Delhi (Yamuna Pusta and Mansarovar Park). The participants were screened for TB symptoms and risk factors to diagnose active PTB in them.ResultsOut of 200 participants, 17 were diagnosed with active PTB. The overall occurrence of Tuberculosis among the studied homeless population was found to be 85 cases per 1000 population. The occurrence of behavioral habits such as smoking was found to be 41.2% (7/17), tobacco chewing at 47.1% (8/17), and alcohol at 47.1% (8/17) among the cases. The occurrence of HIV coinfection was 5.9% (1/17) and diabetes was 5.9% (1/17). The prevalence of TB among homeless females was 1.5 times higher than homeless males but out of 17 diagnosed patients, males had a higher prevalence of TB as compared to females.ConclusionThe occurrence of PTB in the homeless population is quite high as it is also reported in a study in the United States that the national incidence of tuberculosis in the homeless population was 36 cases/100,000 and it needs to be addressed to eliminate tuberculosis.⁷ Moreover, the risk factors such as tobacco, smoking, alcohol, coinfections, etc. might have played a major role in the development of PTB. Also, there is a need for larger studies with large sample sizes to provide evidence against the same.     

Risk factors for death during treatment in pulmonary tuberculosis patients in South India: A cohort study

ObjectiveIdentifying the risk factors for deaths during tuberculosis (TB) treatment is important for achieving the vision of India's National Strategic Plan of ‘Zero Deaths’ by 2025. We aimed to determine the proportion of deaths during TB treatment and its risk factors among smear positive pulmonary TB patients aged more than 15 years.Study designWe performed a cohort study using data collected for RePORT India Consortium (Regional Prospective Observational Research in Tuberculosis).SettingRevised TB Control Program (RNTCP) in three districts of South India.ParticipantsThe cohort consisted of newly diagnosed drug sensitive patients enrolled under the Revised National TB Control Program during 2014–2018 in three districts of southern India. Information on death was collected at homes by trained project staff.Primary outcome measuresWe calculated ‘all-cause mortality’ during TB treatment and expressed this as a proportion with 95% confidence interval (CI). Risk factors for death were assessed by calculating unadjusted and adjusted relative risks with 95% CI.ResultsThe mean (SD) age was of the 1167 participants was 45 (14.5) years and 79% of them were males. Five participants (0.4%) were HIV infected. Among the males, 560 (61%) were tobacco users and 688 (75%) reported consuming alcohol. There were 47 deaths (4%; 95% CI 3.0–5.3) of which 28 deaths (60%) occurred during first two months of treatment. In a bi-variable analysis, age of more than 60 years (RR 2.27; 95%CI: 1.24–4.15), male gender (RR 3.98; 95% CI: 1.25–12.70), alcohol use in last 12 months (RR 2.03; 95%CI: 1.07–3.87), tobacco use (RR 1.87; 95%CI: 1.05–3.36) and severe anaemia (RR 3.53: 95%CI: 1.34–9.30) were associated with a higher risk of death. In adjusted analysis, participants with severe anaemia (<7gm/dl) had 2.4 times higher risk of death compared to their counterparts.ConclusionThough deaths during TB treatment was not very high, early recognition of risk groups and targeted interventions are required to achieve zero TB deaths.     

天津市监狱局囚犯中肺结核病人的DOTS管理及效果分析

目的　评价监狱系统囚犯肺结核病人实施DOTS管理及治疗效果。方法 对2000年天津市监狱局囚犯中发现确诊的369例肺结核病人,实行直接面视下的短程化疗管理(DOTS),并分析其病情转归。结果 初治涂阳肺结核治愈率为93.8%,复治涂阳治愈率为69.2%;涂阳病人规律服药率为92.7%;涂阴病人规律服药率为90.1%。涂阳肺结核病人占全部确诊肺结核病人的14.9%;因释放停止治疗的肺结核病人占7.1%。结论 对监狱系统囚犯肺结核病人实施DOTS管理并取得了一定的成绩。     

Treatment seeking pathways in pediatric tuberculosis patients attending DOTS centers in urban areas of Delhi

Background

The treatment seeking pathways prior to initiation of Direct Observed Treatment Short-course Therapy (DOTS), provides the extent of patient and health system delays among pediatric tuberculosis (TB) patients.

Risk factors associated with default, failure and death among tuberculosis patients treated in a DOTS programme in Tiruvallur District, South India, 2000.

OBJECTIVE: To identify risk factors associated with default, failure and death among tuberculosis patients treated in a newly implemented DOTS programme in South India. DESIGN: Analysis of all patients registered from May 1999 through April 2000. A community survey for active tuberculosis was underway in the area; patients identified in the community survey were also treated in this programme. RESULTS: In all, 676 patients were registered during the period of the study. Among new smear-positive patients (n = 295), 74% were cured, 17% defaulted, 5% died and 4% failed treatment. In multivariate analysis (n = 676), higher default rates were associated with irregular treatment (adjusted odds ratio [AOR] 4.3; 95%CI 2.5-7.4), being male (AOR 3.4; 95%CI 1.5-8.2), history of previous treatment (AOR 2.8; 95%CI 1.6-4.9), alcoholism (AOR 2.2; 95%CI 1.3-3.6), and diagnosis by community survey (AOR 2.1; 95%CI 1.2-3.6). Patients with multidrug-resistant tuberculosis (MDR-TB) were more likely to fail treatment (33% vs. 3%; P < 0.001). More than half of the patients receiving Category II treatment who remained sputum-positive after 3 or 4 months of treatment had MDR-TB, and a large proportion of these patients failed treatment. Higher death rates were independently associated with weight <35 kg (AOR 3.8; 95%CI 1.9-7.8) and history of previous treatment (AOR 3.3; 95%CI 1.5-7.0). CONCLUSIONS: During this first year of DOTS implementation with sub-optimal performance, high rates of default and death were responsible for low cure rates. Male patients and those with alcoholism were at increased risk of default, as were patients identified by community survey. To prevent default, directly observed treatment should be made more convenient for patients. To reduce mortality, the possible role of nutritional interventions should be explored among underweight patients.     

The results of DOTS strategy

Tuberculosis control in Japan is now on the stage of program transition since the declaration of emergency of tuberculosis in 1999. The "21st century DOTS, Japan version" has been proposed under the influence of DOTS experiences in the United States, where drastic reduction of tuberculosis was observed after the introduction of universal DOT. We cannot copy the experiences of US, considering the difference of epidemiological situation of tuberculosis, social background of TB cases and the difference of health infrastructure for TB patients. In the United States, many tuberculosis patients are treated under government health system with DOT. In Japan, TB cases are treated at clinics and hospitals under the integrated health system and public health centers mainly provide prevention services including contact examination of TB and cohort analysis of TB cases. 21st century DOTS, Japan version, is not the universal system at present but it is on the process of implementation and various kind of new activities have been tried including activities to assure the close collaboration between public health centers and clinics, and DOT activities including hospital based DOT, ambulatory intermittent DOT at pharmacies. Here are presented with various experiences both in the field of collaboration between public health centers and clinics, and in the field of DOT. Also here are presented with the calculation which shows the reduction of total cost of tuberculosis treatment by the introduction of ambulatory DOT, considering the influence of recurrence of defaulter cases which would have occurred without DOT. We consider that this symposium is the interim report of the expansion of Japanese DOTS.