Academic journal article Bulletin of the World Health Organization

The DOTS Strategy in China: Results and Lessons after 10 Years. (Theme Papers)

Academic journal article Bulletin of the World Health Organization

The DOTS Strategy in China: Results and Lessons after 10 Years. (Theme Papers)

Article excerpt


In 1991, the Government of China introduced a TB control project using the WHO-recommended, rive-point strategy called DOTS. The project, entitled the Infectious and Endemic Disease Control (IEDC) project, was assisted by a World Bank loan and was implemented in 12 provinces with a population of 573 million, roughly one-half of China's population in 1991. An earlier report of this project reported that the programme expanded rapidly over the first four years (1991-94) to cover 80% of the target population (1). Over 200 000 smear-positive TB cases were diagnosed and, more importantly, nearly 90% of new smear-positive cases were identified. Over 80% of previously treated cases were cured. The initial successes of the IEDC project showed that it was feasible to implement the DOTS strategy on a large-scale.

In June 2002, the IEDC project will end. It has been the largest TB control project in the world to use the DOTS strategy, and in this article we summarize the main results of the project and discuss key lessons. This 10-year experience has important implications for China, as it seeks to sustain and further expand DOTS. The results and lessons may also be of interest to other countries as they scale up their implementation of DOTS.


The project began in April 1991 with rive pilot counties in Hebei province, expanded in April 1992 to 65 pilot counties in all 12 provinces, and thereafter to other counties. Ultimately, the project involved 12 provinces with 1208 counties and a population of 573 million people (1991 population data). Project counties served as demonstration areas and in general they had pre-existing capacity to carry out DOTS. In 1996, Sichuan province split off a municipality called Chongqing. Thereafter, there were 12 provinces and one municipality in the project. To simplify the presentation of data, however, we have reported project results using the old undivided province of Sichuan.

The technical approaches of the project have been described elsewhere (1, 2). Briefly, a standardized diagnostic evaluation was provided free of charge to patients presenting to the county or district TB dispensary. Patients meeting symptom criteria were examined by chest fluoroscopy; those with suspicious fluoroscopy findings submitted three sputum samples for smear examination, and chest X-ray examination was performed if indicated. Patients with smear-positive pulmonary TB received standardized intermittent treatment using streptomycin, isoniazid, pyrazinamide, and rifampin; for retreatment cases, ethambutol was added. Sputum specimens were collected at standardized intervals to document sputum conversion and cure. A health care worker, usually the village doctor (also known as a barefoot doctor), was given a case management fee to directly observe the ingestion of drugs.

Quarterly reports on case-finding, treatment outcome, and other programme activities were submitted from the county to the prefecture, and subsequently to the province and central level. This reporting system permitted the project to be monitored continually. Supervision and quality control activities, conducted from higher to lower administrative levels, maintained the quality of the programme. An extensive training programme was put into place for health care workers involved in the project, from provincial staff to the village doctors.

For each county involved in the project, all data from 1991 to 2000 were analysed by year over the course of DOTS implementation. Time zero was set as the calendar date when each county started implementing DOTS. However, the DOTS implementation data were not analysed by calendar date, since the implementation dates varied between counties. For example, some counties started DOTS in 1992, others in 1993 or 1994. Instead, data collected from each of the counties during the first year they implemented DOTS were referred to as data from the first year of DOTS implementation, and subsequent annual data were numbered consecutively. …

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