Is “Stopping TB in My Lifetime” is possible with Directly Observed Treatment Strategy (DOTS)?

By Anis Rehman, MD

Tuberculosis (TB) is a major healthcare concern across the globe. Worth Health Organization’s (WHO) data speaks for itself. In the year 2010, 8.8 million people acquired TB and 1.4 million died from it. It’s worth to note that, forty percent of the global burden of TB comes from China and India only, While Pakistan also contributes significantly. 

TB has many forms and it can affect virtually any part of the body, however, pulmonary TB is the most common. There are many regimens for the treatment for TB with Anti Tuberculosis Therapy (ATT) and the most widely used consists of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol for the first two months and then Rifampin and Isoniazid for the next four  to six months depending on the prevalence of the drug resistance in that area.

Many causes have been identified which lead to Multi Drug Resistant TB (MDR-TB), defined as resistance to either Isoniazid or Rifampin. The most important and widely agreed upon is lack of compliance for taking the full treatment.

In order to address the issue and increase the compliance, WHO initiated Directly Observed Treatment Strategy (DOTS) in 1995. In the last 15 years 55 million TB patients have been treated under DOTS and 46 million have been known to benefit in terms of cure.

However, despite the application and spending millions of dollars on DOTS, the resistance to ATT has been increasing every day. Extensively Drug-Resistant Tuberculosis (XDR-TB) has emerged in the recent time which is defined as the resistance to any one of inject-able drug and any one of drug from the Quinolones. Hence there have been questions on the DOTS and its success.


According to the Data from WHO, on average, 8 million new cases are being reported from across the globe every year. Volmink J and Garner P, (Cochrane Database 2007) studied 11 randomized and quasi-randomized controlled trials covering 5609 patients from low, middle and high income nations. They concluded that there was no significant difference in cure from DOTS and self administrated ATT in terms of final end point, the cure (RR 1.02, 95% CI 0.86 to 1.21).

A recent systematic review from India by Azhar GS etal., (Lung India. 2012 Apr-Jun; 29(2): 147–153) studied 7 trials from India and concluded that there was more than 10% relapse rate despite the application of DOTS, which is way higher than the stats from the other countries. Hence it can be safely concluded that DOTS has not been very successful.

Application of DOTS to masses lead to have different from those of the pilot studies. Even from the initial years of its application, trials published by Zwarenstein Metal., (Lancet 2001;357:6649) and Walley JD etal., (Lancet 1998;352:13403) pointed that outcomes from DOTS on the TB treatment depend on the compliance of the patients. Patients are not compliant even with the application of DOTS, for example, a study (Ann Acad Med 1995;24:442-6) from China showed that 28.9% of the TB patients failed to complete the full treatment.  Data from the other counties have not been encouraging in this regard.

DOTS rarely happens in its true form in Pakistan along with many lower income countries. Mostly, it has been observed that family members of the patients are assigned to carry out the Modified form of DOTS where healthcare professionals are seen by the patients only once a month to refill their anti tuberculosis medicines. The only way of keeping track is to see the wrappers and that also only proves that the medicine was used up and not that it was actually taken by the patient. This is because of the lack of resources to tackle the great number of patients, hence hindering the application of DOTS in its real form.


Pakistan suffers a deal from TB and thousands of the people die because of this endemic disease. DOTS has been tried here as well, however the results are just the same with a partial success. The point is, is it worth spending millions of dollars each year for some project that is still not successful? While the people suffer from TB as they have been in past!

To sum up in one word, current literature from the renowned and reliable journals has not been in favor for DOTS. There is this simple question that if DOTS has been successful then we won’t be having 8.8 new cases per year and MDR TB would not have been converted into XDR TB for sure. Although there are few countries like Bangladesh where DOTS has been successful, however that is not the case with Pakistan and most of the countries. The time has come when we have to come up with better strategies which are modified to address the local needs of each country in order to make the dream of “Stopping TB in My Lifetime” come true.

Author: Anis Rehman, MD

About the Author: Anis Rehman MD., is a physician, editor, researcher and healthcare activist and holds interests in medical research and healthcare issues. He is the Associate Chief Editor at Journal of Pakistan Medical Students( and writes for medical magazines and blogs. He is also the Country Representative at Healthcare Information For All, UK  (www.HIFA