Falzon, D

Ford, N

Kittle, D

Shafer, J

Small, I

English

MSF Field Research

For personal use. Only reproduce with permission from The Lancet Publishing Group.
THE LANCET • Vol 358 • December 8, 2001 2001
CORRESPONDENCE
DOTS in Aral Sea area
Sir—Reviews  done  by  Médecins  Sans
Frontières  (MSF)  of  its  efforts  to
implement  tuberculosis  treatment  in
western  Uzbekistan  and  northern
Turkmenistan  concurs  with  the  views
expressed  by  Dermot  Maher  and
colleagues (Aug 4, p 421)
1 that putting
patients with tuberculosis in the centre
of their own care is central to the success
of  directly  observed  treatment  short
course (DOTS) for tuberculosis.
The  rapidly  shrinking  Aral  Sea  in
Central  Asia,  resulting  in  loss  of  crop
yield  and  fishing,  has  impinged
negatively  on  the  socioeconomic  status
of the population. Moreover, the effect
on health has been substantial, and the
return of tuberculosis is pathognomonic
of  this  trend.  With  an  incidence  of
tuberculosis  of  100–150  per  100 000
population,  by  MSF’s  estimates,  this
disease  is  a  problem  in  districts
straddling the former Aral Sea coast on
the scale of that in countries in WHO’s
high burden league, such as Russia and
China.
2 MSF  began  working  in  the
region  3  years  ago,  rolling  out  DOTS
among a target population of 3·8 million
spread  over  huge,  largely  desert
expanses.  To  date,  more  than  6000
treatment episodes have been registered.
MSF  has  helped  to  equip  19
diagnostic laboratories for smearing and
microscopy, to train and support health
care workers to use observed treatment
in 13 inpatient facilities and hundreds of
ambulatory  clinics,  to  computerise  the
information system for case registration
and reporting, and to supply drugs and
reagents at no charge to the patients and
the  local  service.  Through  effective
advocacy, it has helped procure external
funding  for  medications  in  Uzbekistan
and  achieve  commitment  from  the
government  of  the  two  countries  to
establish  national  policies  on
tuberculosis in the near future. 
Whereas the mainstay of observation
in our programmes remains the health-
care worker, the internal reviews noted
that distances between the patients and
the  health-care  workers  continue  to
present  a  formidable  obstacle,  making
regular observation of doses, even three
times weekly, difficult to achieve.
Pete Moore
3 has reiterated the need to
reorient  the  role  of  health  workers  in
DOTS, from one of passive observer to
that of counsellor. However, we believe
that he presents insufficient information
on  who  the  alternative  observer  could
be.  There  is  growing  acknowledgment
through  the  official  stand  of  key
international  authorities  on  tuber-
culosis
4,5 that, although the observation
component  is  important,  bringing  the
observer  closer  to  the  patient  is  more
crucial than mandating a professional to
watch patients swallow drugs.
In  the  Aral  Sea  area,  patients’
preference for observers, be it state care
worker,  Red  Crescent  nurse,  family
member,  employer,  or  neighbourhood
committee  members,  will  become  a
priority  to  improve  adherence  to  the
observed methods. Health-care workers’
role would be to provide backup support,
to train and regularly supervise observers,
and to manage arising difficulties, such as
adverse reactions to medication.
J Shafer, D Falzon, I Small, D Kittle, 
*N Ford
Médecins Sans Frontières, Aral Sea Programme,
Tashkent, Uzbekistan
1 Maher D, Raviglione M, Lee JW. Direct
observation for tuberculosis treatment. Lancet
2001; 358: 421.
2 Global tuberculosis control: WHO report
2000. Geneva: WHO, 2000.
3 Moore P. DOTS: what’s in a name. Lancet
2001; 357: 940.
4 Maher D, Chaulet P, Sincaci S, Harries A.
Treatment of tuberculosis: guidelines for
national programmes, 2nd edn. Geneva:
WHO WHO/TB/97.220, 1997: 41.
5 WHO International Union Against
Tuberculosis and Lung Disease, Royal
Netherlands Tuberculosis Association.
Revised international definitions in
tuberculosis control. Int J Tuberc Lung Dis
2001; 5: 213–15.
in  less-developed  countries  has  been
attributed to iatrogenic infection because
of  unsanitary  practices  in  the
plasmapheresis  centres  during  the
aphapheresis.
2
Plasma-donors in poor countries are
unlikely to be injecting drug users; they
are  frequently  poor  people  that  find
selling  plasma  a  way  to  earn  or
supplement  their  earnings.  Viral  RNA
and high titres of specific antibodies for
blood-borne  diseases  in  commercial
plasma-derivative  products,  therefore,
probably reflects the fact that the main
source of plasma used by the industry is
from less-developed countries.
4,5
In  Mexico  in  1986,  there  was  an
outbreak of HIV-1 infection among paid
donors.
2 We  recovered  frozen  plasma
from nine of these HIV-1-positive paid
donors  and  measured  antibodies  to
hepatitis  C  virus.  No  donor  was  an
injecting  drug  user  or  reported
homosexual  contacts.  Seven  proved
positive  for  hepatitis  C  infection.  The
paid  donors  are  probably,  therefore,
infected  with  multiple  blood-borne
diseases  during  plasmapheresis.  Paid
plasma  donors  in  less-developed
countries  such  as  Mexico,  India,  and
China  are  infected  with  HIV-1  and
hepatitis C or B virus.
2
Plasma obtained from less-developed
countries  has  been  trafficked  through
station countries, where brokers relabel
its  source  and  re-export  it  to  the
fractionation  industry,  as  happened  in
Canada and Switzerland and, later, with
Austria  and  South  Africa.  Thus,
commercial  plasmapheresis  in  less-
developed countries puts donors and re-
cipients at risk by contamination of the
plasma pool by blood-borne pathogens.
Recipients  of  products  derived  from
plasma  should  have  the  right  to  know
the country of origin of the plasma; this
information should appear in the label.
Patients  with  hepatitis  C  should  be
asked about history of plasma selling or
of  having  received  plasma-derivative
products. Many patients with unknown
risk  factors  for  hepatitis  C  virus  can
probably be placed in this risk group, as
was proposed a decade ago for HIV.
*Patricia Volkow, Yolanda Lopez-Vidal, 
Rosa Isabel Amieba, Mauricio Hernández
*Departamento de Infectología, Instituto
Nacional de Cancerología, México DF CP 14000,
Mexico; Faculty of Medicine, Universidad
Nacional Autonoma de México; and Instituto
Nacional de Salud Pública, Mexico
1 Guyer B, Bradley DW, Bryan JA, 
Maynard JE. Non-A non-B hepatitis among
participants in a plasmapheresis stimulation
program. J Infect Dis 1979; 139: 634–40.
2 Avila C, Stetler H, Sepúlveda J, et al. The
epidemiology of HIV transmission among
paid donors, Mexico City, Mexico. AIDS
1989; 3: 631–33.
3 Fiedler H. HIV seropositivity in paid donors.
Lancet 1992; 339: 551.
Paid plasma donation and
risk of blood-borne diseases
in blood-product recipients
Sir—Since  the  1970s,  outbreaks  of
blood-borne  diseases  in  plasmapheresis
centres  have  been  described.
1 These
outbreaks  probably  arose  because  of
practices  associated  with  human  blood
injection, reuse of material, and sharing
of  syringes  or  intravenous  lines  during
apheresis. These procedures have made
commercial  plasmapheresis  centres  a
high-risk  environment  for  transmission
and  could  explain  the  high  rates  of
seroconversion for blood-borne diseases
reported among paid donors.
2
Plasma  obtained  through  plasma-
pheresis  from  paid  donors  carries  a
higher risk of blood-borne disease than
that from unpaid donors.
3 The argument
has  been  that  people  who  need  the
money  from  selling  their  plasma  have
risk  behaviours  for  these  infections.  In
more-developed  countries,  however,
injecting  drug  users  or  promiscuous
people  will  be  excluded  by  law  from
being  plasma  donors.  The  high
prevalence  of  different  markers  for
blood-borne diseases in end products of
plasma recorded since 1973 cannot be
explained  by  inclusion  of  high-
risk  donors  from  more-developed
countries.
4,5 By contrast, high prevalence
of blood-borne diseases in paid donors

DOTS in Aral Sea area.

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