Skip to main content
SpringerLink
Log in

The Role of DOTS in Tuberculosis Treatment and Control

  • Current Opinion
  • Published:
American Journal of Respiratory Medicine

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Press Release WHO. Available at: http://www.who.int/gtb/dots/whatisdots.html[Accessed 2003 Apr 7]

  2. Garner P. What makes DOTS work? Lancet 1998; 352: 1326–7

    Article  PubMed  CAS  Google Scholar 

  3. Bayer R, Wilkinson D. Directly observed therapy for tuberculosis: the history of an idea. Lancet 1995; 345: 1545–8

    Article  PubMed  CAS  Google Scholar 

  4. Tuberculosis Chemotherapy Centre, Madras. A concurrent comparison of home and sanitorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ 1959; 21: 51–144

    Google Scholar 

  5. Tuberculosis Chemotherapy Centre, Madras. A concurrent comparison intermittent (twice weekly) isoniazid plus streptomycin and daily isoniazid plus PAS in the domiciliary treatment of pulmonary tuberculosis. Bull World Health Organ 1964; 31: 247–71

    Google Scholar 

  6. Humphries M. Tuberculosis: history of directly observed therapy. Lancet 1995; 346: 380

    Article  PubMed  CAS  Google Scholar 

  7. Moodie AS. Mass ambulatory chemotherapy in the treatment of tuberculosis in a predominantly urban community. Am Rev Respir Dis 1967; 95: 384–97

    PubMed  CAS  Google Scholar 

  8. Stradling P, Poole G. Towards foolproof chemotherapy for tuberculosis. Tubercle 1963; 44: 71–5

    Article  PubMed  CAS  Google Scholar 

  9. Sbarbaro JA. The nature of man and physician. Am Rev Respir Dis 1981; 123: 147

    PubMed  CAS  Google Scholar 

  10. Fox W. Compliance of patients and physicians: experience and lessons from tuberculosis-II. Br Med J Clin Res Ed 1983; 287: 101–5

    Article  PubMed  CAS  Google Scholar 

  11. Brudney K, Dobkin J. Resurgent tuberculosis in New York City. Human immunodeficiency virus, homelessness and the decline of the tuberculosis programme. Am Rev Respir Dis 1991; 144: 745–9

    Article  PubMed  CAS  Google Scholar 

  12. Frieden TR, Sterling T, Pablos-Mendez A, et al. The emergence of drug-resistant tuberculosis: New York City. N Engl J Med 1993; 328: 521–6

    Article  PubMed  CAS  Google Scholar 

  13. Advisory Council for the Elimination of Tuberculosis. Initial therapy for tuberculosis in an era of multidrug resistance: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR Morb Mortal Wkly Rep 1993; 42: RR/7

    Google Scholar 

  14. Morse DI. Directly observed therapy for tuberculosis. Spend now or pay later [editorial]. BMJ 1996; 312: 719–20

    Article  PubMed  CAS  Google Scholar 

  15. Tuberculosis control and research strategies for the 1990s: memorandum from a World Health Organization meeting. WHO Bulletin 1992; 70: 17–21

  16. Doherty MJ, Spence DPS, Davies PDO. Trends in mortality from tuberculosis in England and Wales: effect of age on deaths from non-respiratory disease. Thorax 1995; 50: 976–9

    Article  PubMed  CAS  Google Scholar 

  17. Frieden TR, Fujiwara PJ, Washko RM, et al. Tuberculosis in New York city; turning the tide. N Engl J Med 1995; 333: 229–33

    Article  PubMed  CAS  Google Scholar 

  18. Klein SJ, DiFernindo GT, Naizby BE. Directly observed therapy for tuberculosis in New York city. JAMA 1994; 272: 435–6

    Article  PubMed  CAS  Google Scholar 

  19. Wilkinson D. High-compliance tuberculosis treatment programme in a rural community. Lancet 1994; 343: 647–8

    Article  PubMed  CAS  Google Scholar 

  20. Murray CJL, DeJonghe E, Chum HF, et al. Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries. Lancet 1991; 338: 1305–8

    Article  PubMed  CAS  Google Scholar 

  21. Davies GR, Pillay M, Sturm AW, et al. Emergence of multi-drug resistant tuberculosis in community-based directly observed treatment ptogramme in rural South Africa. Int J Tuberc Lung Dis 1999; 3: 799–804

    PubMed  CAS  Google Scholar 

  22. Kamolratanakul P, Sawert H, Lertmaharit S, et al. Randomised controlled trial of directly observed treatment (DOT) for patients with pulmonary tuberculosis in Thailand. Trans R Soc Trop Med Hyg 1999; 93: 552–7

    Article  PubMed  CAS  Google Scholar 

  23. Zwarenstein M, Schoeman J, Vundule C, et al. Randomised control trial of self-supervised and directly observed treatment of tuberculosis. Lancet 1998; 352: 1340–3

    Article  PubMed  CAS  Google Scholar 

  24. Walley JD, Khan MA, Newell JN, et al. Effectiveness of the direct observation component of DOTS for tuberculosis: a randomised controlled trial in Pakistan. Lancet 2001; 357: 664–9

    Article  PubMed  CAS  Google Scholar 

  25. Moore P. DOTS -what’s in a name? Lancet 2001; 357: 940

    Article  PubMed  CAS  Google Scholar 

  26. Volmink J, Matcgaba P, Garner P. Directly observed therapy and treatment adherence. Lancet 2000; 355: 1345–50

    Article  PubMed  CAS  Google Scholar 

  27. Morris K. WHO sees DOTS. Lancet 1997; 349: 857

    Article  Google Scholar 

  28. Brainard D, Hyslop NE Jr, Mera R, et al. Long-term outcome of inpatients with tuberculosis assigned to outpatient therapy at a local clinic in New Orleans. J Investig Med 1997; 45: 381–7

    PubMed  CAS  Google Scholar 

  29. Davidson H, Schluger NW, Feldman PH, et al. The effects of increasing incentives on adherence to tuberculosis directly observed therapy. Int J Tuberc Lung Dis 2000; 4: 860–5

    PubMed  CAS  Google Scholar 

  30. Davids BL. A controlled comparison of directly observed therapy vs self-administered therapy for active tuberculosis in the urban United States. Chest 1998; 114: 1239–43

    Article  Google Scholar 

  31. Alcaise Megias J, Pascual Torramade J, Altet Gomez MN, et al. Results and epidemiological impact of directly observed treatment of tuberculosis. Arch Bronconeumol 1999; 35: 267–74

    Google Scholar 

  32. Anonymous. From the Centers for Disease Control and Prevention. Evaluation of a directly observed therapy short-course strategy for treating tuberculosis -Orel Oblast, Russian Federation, 1999–2000. JAMA 2001; 28: 1954–6

  33. Edginton ME. Tuberculosis patient care decentralised to district clinics with community-based directly observed treatment in a rural district of South Africa. Int J Tuberc Lung Dis 1999; 3: 445–50

    PubMed  CAS  Google Scholar 

  34. Wilkinson D, Davies GR. Coping with Africa’s tuberculosis burden: are community supervisors an essential component of the DOT strategy? Trop Med Int Health 1997; 2: 700–4

    Article  PubMed  CAS  Google Scholar 

  35. Connolly C, Reid A, Davies G, et al. Relapse and mortality among HIV-infected and uninfected patients with tuberculosis successfully treated with twice weekly directly observed therapy in rural South Africa. AIDS 1999; 13: 1543–7

    Article  PubMed  CAS  Google Scholar 

  36. Olle-Goig JE, Alvarez J. Treatment of tuberculosis in a rural area of Haiti: directly observed and non-observed regimens. The experience of Hôpital Albert Schweitzer. Int J Tuberc Lung Dis 2001; 5: 137–41

    PubMed  CAS  Google Scholar 

  37. Floyd K, Wilkinson D, Gilks C. Comparison of cost effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South Africa. BMJ 1997; 315: 1407–11

    Article  PubMed  CAS  Google Scholar 

  38. Burman WJ, Dalton CB, Cohn DL, et al. A cost-effectiveness analysis of directly observed therapy vs self-administered therapy for treatment of tuberculosis. Chest 1997; 112: 63–70

    Article  PubMed  CAS  Google Scholar 

  39. Moore RD, Chaulk CP, Griffiths R, et al. Cost-effectiveness of directly observed versus self-administered therapy for tuberculosis. Am J Respir Crit Care Med 1996; 154: 1013–9

    PubMed  CAS  Google Scholar 

  40. Snyder D, Chin DP. Cost-effectiveness analysis of directly observed therapy for patients with tuberculosis at low risk for treatment default. Am J Respir Crit Care Med 1999; 160: 582–6

    PubMed  CAS  Google Scholar 

  41. Hilal EH, Jamieson S, Davies PD. The rate of completion of TB treatment in the city of Liverpool, UK. Europ Resp J 2000; 16S31: 500S

    Google Scholar 

  42. Ormerod LP, Bentley C. The management of lymph node tuberculosis notified in England and Wales in 1993. J R Coll Physicians Lond 1997; 31: 666–8

    PubMed  CAS  Google Scholar 

  43. Ormerod LP, Bentley C. The management of pulmonary tuberculosis notified in England and Wales in 1993. J R Coll Physicians Lond 1997; 31: 662–5

    PubMed  CAS  Google Scholar 

  44. Burman WJ, Cohn DL, Rietmeijer CA, et al. Noncompliance with directly observed therapy for tuberculosis: epidemiology and effect on the outcome of treatment. Chest 1997; 111: 1168–73

    Article  PubMed  CAS  Google Scholar 

  45. Sbarbaro JA. Directly observed therapy. Who is responsible? Clin Chest Med 1997; 18: 131–3

    Article  CAS  Google Scholar 

  46. Farmer P. DOTS and DOTS plus: not the only answer. In: Davies P, editor. Drug-resistant tuberculosis: from molecules to macro-economics. Ann N Y Acad Sci 2001; 253: 165–84

    Google Scholar 

  47. Klein SJ, et al. Patient satisfaction with care at directly observed therapy programs for tuberculosis in New York City. Am J Public Health 1999; 89: 1567–70

    Article  PubMed  Google Scholar 

  48. Hurtig AK, Porter JD, Ogden JA. Tuberculosis control and directly observed therapy from the public health/human rights perspective. Int J Tuberc Lung Dis 1999; 3: 553–60

    PubMed  CAS  Google Scholar 

  49. Crofton J. Foreword. In: Davies PDO, editor. Clinical tuberculosis. 1st ed. London: Chapman and Hall, 1994: xv–xvi

    Google Scholar 

  50. Davies PD. New hope for multi-drug resistant tuberculosis [editorial]. Respir Med 2001; 95: 435–6

    Article  PubMed  CAS  Google Scholar 

  51. Ainsworth C, Mackenzie D. Coming home. New Scientist 2001; 171: 28–33

    Google Scholar 

Download references

Acknowledgements

The author has provided no information on sources of funding or on conflicts of interest directly relevant to the content of this article.

Author information

Authors and Affiliations

  1. Tuberculosis Research Unit, Cardiothoracic Centre, Thomas Drive, Liverpool, L14 3PE, UK

    Peter D. O. Davies

Authors
  1. Peter D. O. Davies
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter D. O. Davies.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Davies, P.D.O. The Role of DOTS in Tuberculosis Treatment and Control. Am J Respir Med 2, 203–209 (2003). https://doi.org/10.1007/BF03256649

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03256649

Keywords

Search

Navigation