The Long-Term Health and Economic Benefits of DOTS Implementation in Ecuador

By Oxlade, Olivia; Vaca, Judyth et al. | Canadian Journal of Public Health, January/February 2006 | Go to article overview

The Long-Term Health and Economic Benefits of DOTS Implementation in Ecuador


Oxlade, Olivia, Vaca, Judyth, Romero, Elizabeth, Schwartzman, Kevin, et al., Canadian Journal of Public Health


ABSTRACT

Background: Between April 2001 and March 2004, the Directly Observed Therapy-Short course (DOTS) program was successfully implemented by the National Tuberculosis control program, with assistance from the Canadian Lung Association, in three provinces of Ecuador, where 52% of the population of the country reside.

Methods: Markov modelling was used to project TB-related morbidity, mortality and costs if the former TB control program (status quo) had continued or if the newly expanded DOTS program is maintained over 20 years. Extensive sensitivity analyses were used to determine the effect on projected outcomes of varying key assumptions.

Results: If DOTS is maintained over the next 20 years, we predict that 18,760 cases and 15,812 TB-related deaths will be prevented, resulting in societal savings of $203 million and government savings of $7.1 million (all costs in $US). These findings were robust in extensive sensitivity analyses. Given the initial investment of $3 million for DOTS implementation, this would mean a cost of $190 per life saved.

Conclusions: Implementation of DOTS could yield very substantial public health and economic benefits for Ecuador. These results demonstrate the benefits from Canadian government support for DOTS implementation in low- and middle-income countries.

MeSH terms: Tuberculosis; control; treatment; cost effectiveness; decision analysis

RÉSUMÉ

Contexte : Entre avril 2001 et mars 2004, avec l'aide de l'Association pulmonaire du Canada, le programme équatorien de lutte antituberculeuse a réussi à mettre en oeuvre un programme DOTS (« traitement directement observé sur une courte période ») dans trois provinces de l'Equateur où vit 52 % de la population du pays.

Méthode : Nous avons employé la modélisation par les chaînes de Markov pour calculer les probabilités de morbidité, de mortalité et de coûts liés à la tuberculose si l'ancien programme de lutte antituberculeuse (le statu quo) avait été maintenu ou si le DOTS nouvellement élargi était maintenu au cours des 20 prochaines années. Au moyen d'analyses de sensibilité approfondies, nous avons cherché à déterminer l'effet de diverses hypothèses clés sur les résultats prévus du projet.

Résultats : Si le DOTS est maintenu pendant 20 ans, nous prédisons que 18 760 cas et 15 812 décès liés à la tuberculose seront évités, ce qui économisera à la société des coûts de 203 millions de dollars, et au gouvernement, des coûts de 7,1 millions de dollars (tous les coûts sont en dollars américains). Ces constatations de nos analyses de sensibilité approfondies sont robustes. En supposant un investissement initial de 3 millions de dollars pour la mise en oeuvre du DOTS, le coût moyen par vie épargnée serait de 190 $.

Conclusions : La mise en oeuvre du DOTS pourrait procurer des avantages économiques et de santé publique considérables en Equateur. Ces résultats démontrent les avantages de l'appui du gouvernement canadien à la mise en oeuvre du DOTS dans les pays à faible revenu et à revenu intermédiaire.

Tuberculosis (TB) is a major global problem. The World Health Organization (WHO) has estimated that approximately 8 million persons develop active TB, and 2 million persons die of this disease each year. Between 1998 and 2002, global incidence increased by approximately 1% annually, and by 6% annually in Eastern Europe and SubSaharan Africa.1

Since declaring TB a "global emergency" in 1993, the WHO has coordinated a global effort to improve TB control in high incidence countries, using the "DOTS" strategy - an acronym for Directly Observed Therapy - Short course.2 This strategy emphasizes passive case detection with smear microscopy, and directly observed administration of Rifampin-based regimens. The DOTS strategy is cost effective and has resulted in substantial reduction in TB mortality,3 TB incidence3 and prevalence.4

In 1999, the Canadian International Development Agency (CIDA), with the Canadian Lung Association (CLA) as its executing agency, agreed to assist the National Tuberculosis Programme of the government of Ecuador to implement the DOTS strategy. …

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