Abstract
SETTING: DOTS is a key pillar of the global strategy to end tuberculosis (TB). OBJECTIVE : To assess the effectiveness of communitybased compared with facility-based DOTS on TB treatment success rates in Namibia. METHODS : Annual TB treatment success, cure, completion and case notification rates were compared between 1996 and 2015 using interrupted time series analysis. The intervention was the upgrading by the Namibian government of the TB treatment strategy from facility-based to community-based DOTS in 2005. RESULTS: The mean annual treatment success rate during the pre-intervention period was 58.9% (range 46-66) and increased significantly to 81.3% (range 69- 87) during the post-intervention period. Before the intervention, there was a non-significant increase (0.3%/year) in the annual treatment success rate. After the intervention, the annual treatment success rate increased abruptly by 12.9% (P, 0.001) and continued to increase by 1.1%/year thereafter. The treatment success rate seemed to have stagnated at ∼85% at the end of the observation period. CONC L U S ION: Expanding facility-based DOTS to community-based DOTS increased annual treatment success rates significantly. However, the treatment success rate at the end of the observation period had stagnated below the targeted 95% success rate.
| Original language | English |
|---|---|
| Pages (from-to) | 441-449 |
| Number of pages | 9 |
| Journal | International Journal of Tuberculosis and Lung Disease |
| Volume | 23 |
| Issue number | 4 |
| DOIs | |
| Publication status | Published - 1 Apr 2019 |
Bibliographical note
Funding Information:This study did not receive any specific grant from any funding agency in the public, commercial or non-profit sectors. MRL received salary support through a Canada Research Chair and Michael Smith Foundation for Health (Vancouver, BC, Canada) Research Scholar Award, however, the organisation did not fund this project. Conflicts of interest: none declared.
Funding Information:
The CB-DOTS strategy, which was designed to mitigate the persistently high CNR and low TSR despite the countrywide implementation of FB-DOTS between 1995 and 2004, and which was effectively implemented in Namibia in March 2005 under MTP-I (2004–2009) and MTP-II (2010–2015) for TB and leprosy constituted ‘the intervention’ in the interrupted time series analysis. The strategic goal of CB-DOTS was to improve TB diagnosis, cure and treatment completion through universal access at geographic and patient levels to high-quality community-based TB care. In particular, CB-DOTS aimed to increase the TSR for all patient categories from 65% to 85% by 2009 and to 90% by 2015. To achieve these goals, the CB-DOTS implementation framework designated the National Tuberculosis and Leprosy Programme (NTLP) and health districts (n = 34), as the coordination and implementing units, to work in partnership with up to 14 community-based organisations (CBOs) implementing TB or HIV care. The budget for implementing CB-DOTS was funded by the Government of the Republic of Namibia (51%), the Global Fund (19%) and US Agency for International Development (3%), among others through subgrants to the CBOs. This framework also paved the way for the introduction of FDC drugs for first-line anti-tuberculosis treatment, CB-DOTS training manual and national course, adoption of the World Health Organization guidelines for TB treatment for supporters and universal access to high-quality, low-cost DOT regimens; revised TB guidelines to improve case management and community-based DOT cards to track treatment outcomes were introduced.10,12 By 2015, CB-DOTS coverage had scaled-up one pilot region (Omaheke in 2004) to 12 regions and 27 districts during MTP-I and to all 14 regions and 34 health districts during MTP-II; 529 community health workers (CHWs) (TB cases ~ 1:25 or 529/13 147) were deployed. A team of community-based persons comprising CHWs (community DOT supervisors and facility and DOT nurses), DOT field promoters and community DOT supporters implement the CB-DOTS programme at each health district unit. The CBOs assist the district unit in early identification of TB cases and DOT provision in the community. DOT supporters such as family/relatives, workplace peers or CHWs directly observe the administration of the TB medication at community DOT points, at home and workplaces. For example, in the Omaheke region there were 954 DOT supporters, 858 supervisors and 1189 DOT providers in 2015. In addition, access to quality CB-DOTS services was expanded and scaled-up during MTP-II (2010–2015) to all 14 regions and 34/34 health districts, all 13 regional prisons, collaborative integration in all CBOs and sites implementing community-based HIV care, public-private workplace partnerships and mobile CB-DOT clinics. The quality of CB-DOTS was enhanced by scaling up quality-assured bacteriology laboratories from 30 (1 laboratory per 67 000 people) in 2004 to 36 out of 80 in 2015 to increase case detection, publishing a CB-DOTS training manual and implementing World Health Organization guidelines for TB treatment supporters to standardise treatment with supervision and patient support, creating a system for effective supply and management of anti-tuberculosis drugs as well as a monitoring and evaluation system for effective measurement.
Keywords
- policy analysis
- populationbased
- TB treatment outcome
ASJC Scopus subject areas
- Pulmonary and Respiratory Medicine
- Infectious Diseases
