Directly Observed Therapy (DOTS) Expansion and Enhancement: Presented by Dr. Kisamba Herbert- URC
Implementation of CB-DOTS in a Rural Setting
Community-based DOT implementation is usually linked to a health facility level, which is usually located in a sub-county. The Sub-county Health Worker (SCHW) is a key person in the implementation of community-based DOT.
TB patients who are diagnosed in the health facilities and do not require hospitalization, should be enrolled in community-based DOT.
The SCHW is informed by the health facility staff about the patient and contacts the VHT or the Local Council (LC) I.
The VHT or LCI convenes a community meeting to identify a treatment supporter
whose role is to supervise the patient’s TB treatment in the community.
The SCHW will brief, orient and supervise the treatment supporters. After training is
completed, the SCHW provides the treatment supporter with a 2-week supply of the
anti-TB drugs and a patient treatment card for each patient with TB in the community.
The treatment supporter is responsible for ensuring DOT and recording each dose of
anti-TB drugs swallowed on the patient treatment card. The treatment supporter will
also be responsible for referring the TB patient to the health facility at end of 2 (3), 5
and 8 months for follow-up sputum checks and to monitor the patient for side-effects.
If the treatment supporter identifies TB suspects (e.g., cough of 2 weeks or more
duration) in the community, the treatment supporter should refer them to the health
facility for evaluation.
The SCHW will visit the treatment supporter every 2 weeks during the intensive phase and monthly during the continuation phase to replenish drug supplies, review and record information from the patient treatment card and provide additional training as needed.
The SCHW liaises with both the VHT and LC I to update records and recommend
The following procedures should be observed for TB patients who opt for a family member as a treatment supporter:
Upon diagnosis of TB, the health worker in the health facility must observe the swallowing of the first dose, give a 1-week supply of drugs and request the patient to bring the proposed treatment supporter within the 1 week, before the drugs are finished.
In the event that the TB patient has someone who can be a treatment supporter, the health worker then trains this person to carry out the responsibilities of a treatment supporter.
The health worker should link the treatment supporter to the SCHW.
TB patients who are too ill to be enrolled on community-based DOT should be admitted or referred to a health facility with admission facilities. The health facility nurse will be responsible for observing the swallowing of drugs and recording the information on the patient treatment card. TB patients who are no longer ill enough to require hospitalization will be referred to the nearest health facility and offered community-based DOT.
Implementation of CB-DOTS in an Urban Setting
The management of TB patients in large hospitals and health centres located in urban areas poses special challenges. The advantage of shorter distances from the health facilities is unfortunately counteracted by many factors that include:
the higher cost of services,
the overcrowding of out-patient departments and hospital wards,
the de facto lack of coordination between private and public sector and
the frequent absence of an extended family who can support the patients and their closest relatives during the time of sickness.
As a result, patients can hardly afford to be admitted even for a few days. Furthermore, the majority of patients stop the treatment because of the unaffordable prices of anti-TB drugs in private pharmacies. This poses extremely serious immediate threats to the health of the patients and their families and increases the transmission of TB in an environment that is obviously more populated than the rural areas. Despite all these constraints, the anti-TB treatment must still be observed, completed and evaluated for the sake of curing the patient and controlling TB.
As the social structure and the organization of the health services in large cities are different from that of rural areas, the implementation of DOT must follow different steps.
After the diagnosis of tuberculosis is established:
If the patient’s clinical condition requires admission to a health facility, the nurses start DOT and are responsible for the daily administration of drugs and the daily update of the patient treatment card.
If the patient’s clinical condition allows for immediate referral home, the patient is given the essential information about the disease and its treatment, given the first dose of anti-TB drugs to swallow and is told to return along with a treatment supporter to attend a session of health education and training on how to administer DOT at home.
Patients may receive enough drugs for a few days if they cannot return the following day. They should be told that the drugs are available free of charge.
On returning with the treatment supporter for the health education session (ideally organized twice a week at the health facility), the patient will receive a 2-week drug supply during the intensive phase and a 4-week drug supply during the continuation phase.
Every 2 weeks during the intensive phase, or every 4 weeks during the continuation phase, either the patient or the treatment supporter will return to the health facility to receive a new drug supply, to report any problem/complication of treatment and to allow transposition of information from the patient treatment card to the Unit TB Register. All TB patients admitted for initial treatment will continue DOT at home with the support of a treatment supporter, after their discharge from the hospital.
The key principles for case management of patients treated in urban setting remain the same as those for patients treated with community-based TB care.
An essential component of the CB-DOTS model is the referral system between Diagnostic Unit _ Sub-county Health Worker _ community at LC1, VHT and _ the treatment supporter living close to the patient. This referral system cannot be reproduced in urban areas because of their different social organization and because the primary healthcare (PHC) system is weaker.
The Sub-County Health Worker (SCHW)
The SCHW is the key resource person for DOTS implementation at sub-county level.
The SCHW should be based at a health facility. It is the responsibility of the health facility in-charge together with the HSD focal person and DTLS to select a suitable SCHW. The broad definition of the title allows for flexibility in identifying the most suitable health worker (nurse, laboratory staff, nursing assistant, health educator, leprosy assistant, and health assistant, etc.) for this role in each area.
SCHWs are the link between the formal health services and the community through the village health teams (VHTs), the Local Council I (LC I) and treatment supporters. They will integrate CB DOTS-related activities and visit local communities, with other routine duties in order to make their field work the most cost-effective.
The following are the responsibilities of the SCHW:
i) Approach the community through VHTs and Local Council I and motivate them to identify
and select treatment supporters
ii) Train treatment supporters
iii) Provide regular support supervision of treatment supporters
iv) Conduct ACSM activities
v) Regularly deliver drugs and other supplies to treatment supporters
vi) Liaise with treatment facility at sub-county level to receive notifications of new patients,
give feedback on patients’ DOT in order to update unit registers, and refer patients with
vii)Maintain an updated sub-county health register
viii) Advise VHTs or LC I about compliance of patients and treatment supporters
ix) Identify TB suspects and carrying out contact tracing
Note: Any SCHW who does not perform to expectations should be replaced.
Treatment Supporter Roles
Treatment supporters are identified in the village meeting involving VHT, LC1 and community members.
They help TB patients adhere to the taking of anti-TB drugs. A treatment supporter
should live near enough to the patient being supported to carry out the following tasks and responsibilities:
i) To observe the patient taking the daily dose of anti-TB drugs correctly
ii) To tally the drug intake day by day on the patient’s treatment card
iii) To ensure uninterrupted availability of drugs. In the rare event that the SCHW is delayed,
the treatment supporter should collect the drugs from the health facility.
iv) To remind the patient to go for sputum follow-up examinations at 2 (3), 5 and 8 months of
v) To encourage the patient to continue taking treatment
vi) To keep the patient’s drugs safe
vii)To inform the SCHW of any problem related to the health of the patient or to any
constraint in administering DOT
The treatment supporter is therefore responsible to the SCHW and the community. It is recommended that the treatment supporter should have the following characteristics:
a) be a resident of the community, such as a neighbor, family member or another
b) have a minimum level of literacy (able to read and write)
c) be identified by the community and accepted by the patient
d) understand and accept the role of treatment supporter
Note: A TB/HIV co-infected patient on both ART and anti-TB medication should have
the same treatment supporter for both conditions.