Tuberculosis control in Vietnam : Directly observed treatment, short-course (DOTS) - the role of information and education

Abstract: Background: In 1993, the WHO declared tuberculosis (TB) a global emergency. At the same time, the DOTS strategy was recommended for controlling TB. DOTS focuses on sputum smear positive pulmonary TB patients who present themselves to a health facility for diagnosis. Vietnam has met the WHO targets for both case detection rate (>= 70%) and successful treatment rate (>= 85%) during the eight most recent years. Despite persistently high case detection and cure rates, there is no evidence of decreased TB incidence. Objective: to study components of the DOTS strategy related to information and education among health care staff and the general public, as well as to analyse case detection in a rural area in Vietnam. Methods: The studies were conducted in a demographic surveillance site (FilaBavi) in Bavi district and in a sample of 42 randomly selected districts in the north and central regions of Vietnam. Those persons with prolonged cough in the sample of 35,832 individuals aged 15 or above in FilaBavi, were interviewed about their health seeking behaviour and TB knowledge. Those interviewed also provided sputum samples for AFB and a chest X-ray for TB diagnosis. TB notification and mortality rates were analysed for prolonged cough cases covering 1,384 person-years of observation over a two and a half-year period. Knowledge and practices regarding TB care were assessed among 253 health care staff in Bavi district. Knowledge about TB and its treatment was examined among 364 TB patients in 42 districts in 27 provinces of Vietram. Results: Individuals who reported a prolonged cough had limited knowledge of the suggestive symptoms of TB, causes, transmission mode, and curability of TB. Forty-eight percent of prolonged cough respondents did not know any suggestive symptoms of TB. TB patients had high knowledge levels regarding the curability and suggestive symptoms of TB. However, knowledge about the cause of TB and the structure of follow-up sputum examinations was low among TB patients. Among prolonged cough cases, 74% sought care outside the public health sector for their first health care action. Better TB knowledge was significantly related to having sought health care and seeking hospital care. Individuals who did not know any suggestive symptoms of TB more commonly used selfmedication or less qualified health care providers (such as private practitioners and pharmacies) for their first health care action, than people who knew TB symptoms (80% vs. 68%, p<0.01). Individuals who knew TB symptoms visited a hospital more commonly than people who did not know the symptoms (30% vs. 17%, p<0.001). Fortyseven percent of the health care staff answered at least 17 out of 23 questions correctly. Health care staff´s theoretical knowledge about TB was better than their knowledge related to practices. District hospital staff had lower-thanexpected knowledge about TB. The estimated "true" prevalence of smear positive pulmonary TB was 100/100,000 population (95% Cl 71-138). The case detection rate of the National TB Programme (NTP) in Bavi district (45%; 95% Cl 36-55) is lower than the reported case detection rate for Vietnam of 80%. The TB notification rate for the prolonged cough cohort was significantly higher than that of the general population (RR 11.06; 95% Cl 8.2814.77). Mortality rates for the prolonged cough group were 18.96 for men, 11.85 for women, and 15.33 total. These rates were higher than those in general population (6.71, 5.12, and 5.87 per 1,000 person-years respectively). Conclusions: These studies provide evidence of low levels of knowledge about TB, which is of relevance to the currently used DOTS strategy. Knowledge about TB within the population was low despite NTP health education programmes. Knowledge and practices regarding TB and the NTP among health care staff at basic health care facilities were insufficient. Limited TB knowledge significantly affects health seeking behaviour and influences case detection, which is based on self-referral as recommended by the DOTS strategy. A lower-thanNTP-estimated case detection rate of smear positive TB, especially among women, was found. Individuals with prolonged cough were associated with an increased risk of contagious TB and of dying. Findings from the studies show that suitable and culturally appropriate information about TB and the NTP should be taken into consideration within health education programmes. A possible extension of the DOTS strategy, including an improved follow-up system for TB risk groups and active case finding activities in some sub-groups, should be evaluated.