title: Impact of DOTS compared with DOTS-plus on multidrug resistant tuberculosis and tuberculosis deaths: decision analysis.
abstract: OBJECTIVE
  This study sought to determine the impact of the World Health Organization's directly observed treatment strategy (DOTS) compared with that of DOTS-plus on tuberculosis deaths, mainly in the developing world.
  
  
  METHODS
  Decision analysis with Monte Carlo simulation of a Markov decision tree.
  
  
  METHODS
  People with smear positive pulmonary tuberculosis.
  
  
  METHODS
  Analyses modelled different levels of programme effectiveness of DOTS and DOTS-plus, and high (10%) and intermediate (3%) proportions of primary multidrug resistant tuberculosis, while accounting for exogenous reinfection.
  
  
  METHODS
  The cumulative number of tuberculosis deaths per 100 000 population over 10 years.
  
  
  RESULTS
  The model predicted that under DOTS, 276 people would die from tuberculosis (24 multidrug resistant and 252 not multidrug resistant) over 10 years under optimal implementation in an area with 3% primary multidrug resistant tuberculosis. Optimal implementation of DOTS-plus would result in four (1.5%) fewer deaths. If implementation of DOTS-plus were to result in a decrease of just 5% in the effectiveness of DOTS, 16% more people would die with tuberculosis than under DOTS alone. In an area with 10% primary multidrug resistant tuberculosis, 10% fewer deaths would occur under optimal DOTS-plus than under optimal DOTS, but 16% more deaths would occur if implementation of DOTS-plus were to result in a 5% decrease in the effectiveness of DOTS CONCLUSIONS: Under optimal implementation, fewer tuberculosis deaths would occur under DOTS-plus than under DOTS. If, however, implementation of DOTS-plus were associated with even minimal decreases in the effectiveness of treatment, substantially more patients would die than under DOTS.
authors.affiliation: Johns Hopkins University Center for Tuberculosis Research, 424 N Bond Street, Baltimore, MD 21231, USA. tsterls@jhmi.edu
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Sterling
authors.forename: Harold P
authors.initials: HP
authors.lastname: Lehmann
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Frieden
mesh_terms: D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D023801:Directly Observed Therapy / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D009010:Monte Carlo Method; D011336:Probability; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy / Q000401:mortality*; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy / Q000401:mortality*