Introduction and outcome of DOTS projects in Japan

Although Japan has overcome a sever epidemic of tuberculosis before World War II in a world fastest rate through improvement in the living standard and collective implementation of the TB control projects. In addition Japan has contributed to international cooperation for TB control since 1950 and recent projects regarding introduction and development of DOTS system to a series of countries has resulted in significant improvement of treatment success rate. From domestic point of view, however Japan has been based on an isolation of the patients with direct smear positive and self-assessed medication until the end of 20th century, not being listed among nations adopting DOTS strategy against TB. In Japan DOTS has been introduced to some chosen areas in modified style since 2000. In the current symposium the outcome of DOTS system were presented along with future direction of the system. Dr Yamazaki, chief nurse of TB ward of Osaka Prefectural Center of Respiratory and Allergic Disease reported their path in introducing in-hospital DOTS system and its expansion to other institutes. They have already voluntarily developed and maintained telephone-mediated patient support system for discharged patients many years precedent to DOTS system application. Based on a concept that completion of full chemotherapy is essential for the cure of TB they established DOTS system especially for those patients transferred to other medical services after introducing anti-TB chemotherapy in the center under co-operation with Department of Health in the Ministry of Health of Osaka city. According to cohort evaluation after January 2001 they reported dramatic reduction of the default rate of treatment from 21.1% between 1996 and 1999 to 2.5% in 2001. Dr Ohtani reported the process of the introduction and development of DOTS system to the selected area named Kotobuki area covering 0.16 km² where TB incidence rate was approximately 1700 per 100,000. The trail became the milestone of the DOTS in Japan. The population of the area is approximately 6,000 under supplementary benefit. The DOTS system based on the combination of in-hospital DOT at the NHO Minami-Yokohama National Hospital and DOT in the private clinic in the area after discharge under close co-operation with the Department of Health in the Ministry of Health of Yokohama city. The first memorial DOTS conference was held at the Minami-Yokohama National Hospital. The key of the success of the project lies in the involvement of the private clinic of the district. The primary practitioner of the clinic, Dr Saiki observed and supported DOT after discharge with high motivation, deep understanding of the DOTS project and the trust by the resident in the district. After implementation of the system TB and cohort evaluation demonstrated significant decrease in the incidence rate of TB. At the time of 2005 the concept of DOTS seems to be generally accepted by the Kotobuki society. Dr Wada from Research Institute of Tuberculosis has introduced the effect of short DOTS strategies cooperating with pharmacy using intermittent treatment program. The fruitful results give a new insight into the wide propagation of the systems. The more the social commitment of the pharmacists in the patient education achieving better adherence, the more the chances of the successful introduction of the system. The effectiveness of intermittent anti-TB medication is also bring strong impact on the controlling system of TB by make it possible to allocate the limited budget to more effectively. The straight co-operation between public service and private hospitals and other institutes. While the results of the DOTS strategies of each project in the symposium are demonstrated in a only few figures and tables those fruits result from dense as well as heavy efforts made by every people including not only medical employee but also patients. Systematic social support system for each patient with TB to finish treatment to the end is essential to improve TB rate especially in Japan where all medication was evaluated on self-assessment. Prescription of regimen including PZA for initial 2 months is merely a part of total treatment regimen and is insufficient to control the disease. Those who returned to be contagious due to interruption of chemotherapy are not necessarily symptomatic resulting in the spread of diseases. It is needed to make more effort on education regarding tuberculosis so those patients could receive the full treatments and be cured. The current reports demonstrate not only successful attainment of the initial aim at introducing DOTS in modified form to Japan also its dramatic effectiveness would generate further expansion of the DOTS strategy across the nation. Although DOTS system has been appropriately modified and introduced to Japan in various mode constant efforts have to be made to realize DOTS as recommended by WHO, overcoming a series of obstacles. The most important determinant on to achieve success of DOTS project lies in synergy between control technology and the infrastructure supporting the technology. Even though Japan is regarded among economically most developed countries the biggest problem in promotion of DOTS is personnel and budget. Although it appears to be expensive an improvement of treatment performance would finally result in low expense. Now it is the time for the government to show its solid responsibility for commitments of TB control including DOTS. 1. Introduction and its effectiveness of DOTS program based on the institute: Katsuko YAMAZAKI (Chief of Nursing Division, Osaka Prefectural Center of Pulmonary and Allergic Medicine) Based on the vital importance of adherence to chemotherapy for the successful management of TB we established DOTS system especially for those patients transferred to other medical services after introducing anti-TB chemotherapy in our center under corporation with Osaka municipal health administer. Our newly developed system introduced from January 2001 dramatically reduced the rate of treatment failure from 21.1% between 1996 and 1999 to 2.5% in 2001. 2. Introduction of DOTS system to Kotobuki area in Yokohama and its accomplishment: Sumire OTANI (NHO Minami-Yokohama National Hospital) DOTS, new strategy to control TB recommended by WHO moved national hospital and Yokohama municipal health administry to develop its modified form in Kotobuki area where TB prevalence rate is as high as in 2000. Compared with the situations in 1998, percentage of treatment finishing rate improved from 68.9% to 97.3% resulting in the outstanding decrease of from 1700 to 778.2 in five years. Special commentaries: The role of private clinic to lead DOTS project to success in the Kotobuki area in Yokohama: Teruko SAIKI (Director of Kotobuki Clinic) The DOTS systems was introduced to the Kotobuki area in which people are living on the Livelihood Protection Law. It is suggested that key elements leading the project to success were to convey them a passion to control tuberculosis in their society and ensure them an isolated comfortable space. These background render patients to accept DOTS without hesitation. 3. DOTS with intermittent anti-tuberculosis chemotherapy in a pharmacy setting decreased the frequency of defaulters in Japan: Masako WADA (Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association), Kunihiro MIZOGUCHI (Fukujuji Hospital, Japan Anti-Tuberculosis Association) A total of 132 new pulmonary TB patients were treated with intermittent chemotherapy under the supervision of a pharmacist during the continuation phase. The pharmacist supervised patients taking medications at the pharmacy. Our DOT system was effective and convenient and prevented the interruption of treatment. The frequency of adverse drug effects was only 0.2%. The DOTS system model employed in the study should be expanded in Japan.