DOTS implementation in a middle-income country: development and evaluation of a novel approach.

BACKGROUND: DOTS is widely accepted as the most cost-effective strategy for tuberculosis (TB) control. However, there is little published information regarding methods for implementation in middle-income countries. METHODS: Over 3 years, the Canadian Lung Association assisted the Ecuadorian TB programme to implement DOTS for over half the nation's total population. A multilevel strategy developed by a team of Ecuadorian health professionals provided initial, in-service, replica and reinforcement training at the local level, and training at national level for specialist physicians, specialist societies and medical schools. Evaluation was based on international guidelines for case finding, treatment and laboratory quality control, and costs of all implementation activities. RESULTS: By January 2004, DOTS training had been provided to 1954 health professionals and 199 smear microscopy technicians, and DOTS was implemented in all 496 health facilities. Case detection activities at the local level increased substantially. Cure and treatment completion improved to 83% of new cases. Overall concordance of laboratory quality control readings was 98.7%. The total cost of DOTS implementation was US dollar 3 049 585. CONCLUSIONS: To achieve international targets for TB control, DOTS implementation in a middle-income country required intensive training at the local level and at multiple other levels.

Patient and family costs associated with tuberculosis, including multidrug-resistant tuberculosis, in Ecuador.

BACKGROUND: There is little published information on the costs of multidrug-resistant tuberculosis (MDR-TB) for patients and their families in low- or middle-income countries. METHODS: Between February and July 2007, patients with microbiologically confirmed active TB who had received 2 months of treatment completed an interviewer-administered questionnaire on direct out-of-pocket expenditures and indirect costs from lost wages. Clinical data were abstracted from their medical records. RESULTS: Among 104 non-MDR-TB patients, total TB-related patient costs averaged US$960 per patient, compared to an average total cost of US$6880 for 14 participating MDR-TB patients. This represents respectively 31% and 223% of the average Ecuadorian annual income. The high costs associated with MDR-TB were mainly due to the long duration of illness, which averaged 22 months up to the time of the interview. This resulted in very long periods of unemployment. Most patients experienced a significant drop in income, particularly the MDR-TB patients, all of whom were earning less than US$100/month at the time of the interview. CONCLUSION: Direct and indirect costs borne by patients with active TB and their families are very high in Ecuador, and are highest for patients with MDR-TB. These costs are important barriers to treatment completion.

Relationships between serum concentrations of C-reactive protein and micronutrients, in patients with tuberculosis.

Studies on the serum concentrations of micronutrients in tuberculosis (TB), and their relationship to the acute-phase response (APR), are scarce. The serum concentrations of zinc, copper, selenium and vitamins A and E in 46 smear-positive cases of pulmonary TB (PTB) from Ecuador were therefore compared with those in 10 healthy Ecuadorian volunteers, and the correlations between these concentrations and the serum concentration of C-reactive protein (CRP) were evaluated. Compared with the healthy volunteers, the PTB cases had significantly lower serum concentrations of zinc, retinol and selenium and significantly higher serum concentrations of copper. Both groups had moderately high concentrations of selenium in their sera. The PTB cases who had >50 mg CRP/ litre (a concentration indicative of an APR) had lower serum concentrations of retinol and zinc than the cases with lower CRP concentrations. In patients with PTB, hypozincaemia and hyporetinolaemia are strongly associated with the APR. It is therefore necessary to consider the extent of activation of the APR when interpreting serum micronutrient concentrations in patients with TB.