MORE THAN TEN YEARS OF DOTS IN BOSNIA AND HERZEGOVINA

Directly Observed Th erapy Short-course (DOTS) is composed of fi ve distinct elements: political commitment, case detection through quality-assured bacteriology; drug supplies; surveillance and monitoring systems and use of highly effi cacious regimens; and direct observation of treatment. DOTS produces cure rates of up to  percent even in the poorest countries and prevents the development of Multi-Drug Resistant Tuberculosis. National TB Programme (NTP) has been started to introduce in  according to DOTS principles in B&H with central and regional levels. At central levels there are national TB coordinators, and in all Cantons/Regions there are regional TB Coordinators. During intensive phase of therapy, patients are hospitalized. In the second phase of therapy, patients are treated in anti-tuberculosis dispensaries and some of them by a responsible member of the family (family supervision). Th ere are several weaknesses in implementation of DOTS in B&H: TB case detection was not fully implemented in all medical services. Registration of TB cases in some facilities, there is no offi cial central recommended registry, individual reporting for treatment outcomes and establishing a reliable monitoring and evaluation system. Application for  round of Th e Global Fund to Fight AIDS, TB and Malaria (GFATM) had been fi nally approved and signed for B&H in October . Th ese grants would repair some implementation gaps and improve DOTS strategy in B&H.


Introduction
Directly Observed Therapy Short-course (DOTS) is composed of fi ve distinct elements: political commitment, case detection through quality-assured bacteriology; drug supplies; surveillance and monitoring systems and use of highly effi cacious regimens; and direct observation of treatment.WHO generally uses the term to mean the fi ve components of DOTS.But the word "DOTS" is an acronym for Directly Observed Th erapy Short-course.Many workers therefore interpret DOTS purely as direct supervision of therapy.In fact it has two purposes, to ensure that the patient with tuberculosis (TB) completes therapy to cure and to prevent drug resistance from developing in the community ().Political commitment is needed to foster national and international partnerships, which should be linked to longterm strategic action plans prepared by National TB Programmes (NTPs).Strategic action plans should address technical and fi nancial requirements and promote accountability for results at all levels of the health system ().
Case detection through quality-assured bacteriology for diagnosis remains the recommended method of TB case detection, first using sputum smear microscopy and then culture and drug susceptibility testing (DST).A wide network of properly equipped laboratories with trained personnel is necessary to ensure access to quality-assured sputum smear microscopy.In addition, every country should have a well-resourced and fully functioning national reference laboratory.The laboratory network should be based on the following principles: adoption of national standards in accordance with international guidelines; decentralization of diagnostic services, with high profi ciency levels maintained; communication among members at various levels of the network; and functioning internal and external quality management, including supervision.Culture and DST services should be introduced, in a phased manner, at appropriate referral levels of the health system.Th eir functions should include diagnosis of sputum smear-negative TB, diagnosis of TB among HIV-positive adults and children, diagnosis and monitoring of response to treatment of MDR-TB, and testing related to periodic surveys of the prevalence of drug resistance.Maintaining the quality of the laboratory network depends on regular training, supervision and support, and motivation of laboratory staff .Drug supply with standardized TB drugs, with supervision and patient support is the mainstay of TB control organizing and administering across the country for all adult and pediatric TB cases -sputum smear-positive, smear-negative, and extra pulmonary.In all cases, WHO guidelines on patient categorization and management should be followed ().Th ese guidelines emphasize use of the most eff ective standardized, short-course regimens, and of fi xed-dose drug combinations (FDCs) to facilitate adherence to treatment and to reduce the risk of the development of drug resistance.Separate WHO guidelines are also available for management of patients with drug-resistant TB ().Th e TB recording and reporting system is designed to provide the information needed to plan, procure, distribute and maintain adequate stocks of drugs.Anti-TB drugs should be available free of charge to all TB patients.Th e Global Drug Facility (GDF) and the Green Light Committee off er countries with limited capacity the benefit of access to quality-assured TB drugs at reduced prices and also facilitate access to training on drug management ().Establishing a reliable monitoring and evaluation system with regular communication between the central and peripheral levels of the health system is vital.Th is requires standardized recording of individual patient data, including information on treatment outcomes, which are then used to compile quarterly treatment outcomes in cohorts of patients.These data, when compiled and analyzed, can be used at the facility level to monitor treatment outcomes, at the district level to identify local problems as they arise, at regional or national level to ensure consistently high-quality TB control, and nationally and internationally to evaluate the performance of each country.Regular programme supervision should be carried out to verify the quality of information and to address performance problems.DOTS produces cure rates of up to   even in the poorest countries and prevents the development of MDR-TB by ensuring the full course of treatment is followed.By the end of , all  of the high burden countries which bear  of the estimated incident cases had adopted DOTS.Th e need to carry out specifi c interventions in addition to training in DOTS in universities and medical schools in order to improve TB control is discussed.A specific project in this area developed by the IUATLD in Latin America ().

DOTS implementation in Bosnia and Herzegovina
In former Yugoslavia, Bosnia & Herzegovina had very high TB incidence rate over /  population till , and it's slightly decreased between  and .During the War in B&H DOTS strategy and National TB Programme (NTP) has been started to introduce in  according to DOTS principles.In both Entities of B&H, Federation of Bosnia and Herzegovina (FB&H) and Republika Srpska (RS) was established central level, and regional levels too,  in each canton of FB&H, and  in each region of RS, and one in District Brčko (DB).At central levels there are national TB coordinators, and in all Cantons/Regions there are TB Coordinators, and one in DB.All of them work on implementation of DOTS strategy in the whole country.NTP organization on each level (regional and local) have responsibility for close collaboration with Central Unit (Central level) based on activities planned for Cantons-Regions: planning, supervision and control activities (drugs supply, TB lab equip-ment supplies, documentation, correct reporting, training, case fi nding, reporting on treatment results).During intensive phase of therapy, patients are hospitalized.In the second phase of therapy, patients are treated in antituberculosis dispensaries (PFD) and some of them by a responsible member of the family (family supervision).After several years of implementation all B&H was covered with DOTS.B&H was categorized in category  by degree of DOTS implementation (coverage with DOTS is  -WHO Report , p ).National TB program (NTP) in Bosnia and Herzegovina was approved * incidence/100.000population

Results
Recording and reporting system reached WHO international standards with yearly reports through "Data collection form" and some of these data were presented in the next tables and fi gures:.
• No data during war in B&H Table . and ., and also Figure . and . show that the number of TB registered cases and incidence rate were gradually decreased.During the war in B&H there were no recording and reporting system, so there were no data on TB cases.After  the number of TB cases was signifi cantly smaller than before Th e War.

Conclusion
During resent years NTPs of B&H had activities on DOTS implementation improvement.So far Application for  round of Th e Global Fund to Fight AIDS, TB and Malaria (GFATM) had been fi nally approved and signed in October .
Th ese grants would repair some implementation gaps and improve implementation of DOTS strategy in B&H.Application for  round of Th e Global Fund to Fight AIDS, TB and Malaria (GFATM) had been fi nally approved and signed for B&H in October .Th ese grants would repair some implementation gaps and improve DOTS strategy in B&H.

TABLE 1 .
Number of registered TB cases and TB incidence rate inBosnia and Herzegovina in period 1984-2005

TABLE 2 .
TB Incidence rate inBosnia and Herzegovina in period 1984-2005

TABLE 3 .
Number of New pulmonary smear positive TB cases in Bosnia and Herzegovina in 2004 Th e reason for it was smaller population, but decreasing TB incidence rate shows better TB control in the whole country.Incidence rate in B&H approaches gradually to the middle range incidence (- TB cases/  population).New pulmonary smear-positive TB cases belongs - and elder age groups, like in western European countries.(Table and Figure .)Table .and Figure .show that extra-pulmonary tuberculosis in B&H was under  of all TB cases, except in .Usually *unk -unknown

TABLE 4 .
Number of registered all TB cases, pulmonary and extrapulmonary and TB incidence rate in Bosnia and Herzegovina in period 1984-2005 it can be till  of all TB cases.In the next table and fi gure were presented the results of treatment: TB outcome results presented on Table .and Figure  are very high -cure rate > for new TB cases, and ,  for re-treatment TB cases.

TABLE 5 .
Treatment results for new and re-treatment TB cases in B&H in 2003 cal result().Th is retrospective study shows postoperative blood sugar levels in patients who had CABG.Th ree groups of patients were considered.The first group included patients who had diabetes before surgical intervention and were treated with peroral antidiabetic.Th e second group included patients already taking insulin, while the third group consisted of patients without diabetes and served as the control.Th e results show that all three groups had increased values of blood sugar on the fi rst postoperative day.Th e importance of glycaemia control on the fi rst postoperative day was also analyzed in previous studies.Mc Alister et al.()proved that it is very important to decrease the levels of glycaemia on the fi rst postoperative day.Th is is due to the fact that during this day, the values of glycaemia increase by  mmol/l which in turn relates to greater risk of unwanted side eff ects.Hyperglycaemia can lead to dehydration, electrolyte disbalance and arrhythmia.It is considered that these complications occur when glycaemia values exceed  mmol/l().Certain studies indicate that continuous insulin infusion following CABG exerts better control of glycaemia than insulin injections (, ).Patients with better glycaemia control stay shorter period of time in intensive care unit, they do not develop sternal wound infections and thus, the cost of treatment is lower.Study shows that the patients from the first group, who receive peroral therapy, need insulin after surgical intervention to treat diabetes.Stress during operation and administration of several medications after operation may also cause increased insulin resistance and distort glycaemia control.