Feasibility of implementing public-private mix approach for tuberculosis case management in Pokhara Metropolitan City of western Nepal: a qualitative study

Background

The Public-Private Mix (PPM) approach is a strategic initiative that involves engaging all private and public health care providers in the fight against tuberculosis using international health care standards. For tuberculosis control in Nepal, the PPM approach could be a milestone. This study aimed to explore the barriers to a public-private mix approach in the management of tuberculosis cases in Nepal.

Methods

We conducted key informant interviews with 20 participants, 14 of whom were from private clinics, polyclinics, and hospitals where the PPM approach was used, two from government hospitals, and four from policymakers. All data were audio-recorded, transcribed, and translated into English. The transcripts of the interviews were manually organized, and themes were generated and categorized into 1. TB case detection, 2. patient-related barriers, and 3. health-system-related barriers.

Results

A total of 20 respondents participated in the study. Barriers to PPM were identified into following three themes: (1) Obstacles related to TB case detection, (2) Obstacles related to patients, and (3) Obstacles related to health-care system. PPM implementation was challenged by following sub-themes that included staff turnover, low private sector participation in workshops, a lack of trainings, poor recording and reporting, insufficient joint monitoring and supervision, poor financial benefit, lack of coordination and collaboration, and non-supportive TB-related policies and strategies.

Conclusion

Government stakeholders can significantly benefit by applying a proactive role working with the private in monitoring and supervision. The joint efforts with private sector can then enable all stakeholders to follow the government policy, practice and protocols in case finding, holding and other preventive approaches. Future research are essential in exploring how PPM could be optimized.

Knowledge and Practice on Prevention and Control of Tuberculosis Among Nurses Working in a Regional Hospital, Nepal

Introduction

Tuberculosis (TB) is a highly prevalent communicable disease in Nepal. All health personnel who care for such patients are at high risk of developing tuberculosis. It is very necessary for all healthcare providers, especially nurses, who spend a lot of time with such patients, to have adequate knowledge and correct practice on the occupational safety measures to maintain health and prevent transmission of the disease. This study was carried out to assess the knowledge and practice of nurses in the prevention and control of TB infection.

Method

This study was a cross-sectional study conducted on nurses working in all wards and Outpatient Departments (OPDs) of Western Regional Hospital, Pokhara, Nepal. A complete enumeration of the respondents was performed, and data were collected consecutively, using a semi-structured self-administered questionnaire, from all nurses working in all the wards and OPDs of the hospital. The predictors of knowledge of TB infection prevention and control (TBIPC) were assessed using binary logistic regression.

Results

The study findings showed that a majority of nurses had an inadequate level of knowledge and poor practice of prevention and control of TB. Regarding practice, none of the nurses reported the use of an N95 mask or a respirator during care of the patients with TB and all the nurses reported that they used chemical disinfectant (virex) to clean the room and the surfaces. However, none of them reported the use of fumigation or ultraviolet irradiation for disinfection. Nurses who were 40 years and older (p = 0.001, adjusted odds ratio (AOR) = 5.965, CI = 2.083–17.457) and who were currently working in the wards with isolation rooms demonstrated higher odds for knowledge on TBIPC (p = 0.010, AOR = 2.686, CI = 1.264–5.710).

Conclusions

This study showed that a majority of nurses had an inadequate level of knowledge and implemented poor safety measures for the prevention and control of tuberculosis. This increases their risk of being infected with TB infection and cross-transmission. It is recommended that the hospital plan and conduct the necessary education/training for nurses to update their knowledge, develop the organizational structure and policies, and establish a system to support and monitor the practice of health workers on the prevention and control of TB, and maintain the health and safety of nurses caring for patients with TB.

Prevalence and associated risk factors for tuberculosis among people living with HIV in Nepal

Background

Worldwide tuberculosis (TB) takes more lives than any other infectious diseases. WHO estimates around 68,000 incident TB cases in Nepal. However, in 2018 only around 27,232 new TB cases were reported in the national system, resulting around 40,768 incident TB cases missing every year in Nepal. National Tuberculosis Control Center carried out this study in anti-retroviral therapy (ART) sites to estimate the prevalence of TB and identify the associated risk factors for TB among the people living with Human Immunodeficiency Virus (PLHIVs) in Nepal.

Methods

It was a cross-sectional institution-based study conducted between March and August 2018. Six ART sites with high caseloads of PLHIVs were selected. PLHIVs who were equal or above 18 years of age and were in ART program at the selected study sites were considered eligible for the study. Diagnosis of tuberculosis among PLHIVs who agreed to participate in the study was carried out as per the National Tuberculosis Management Guideline of National Tuberculosis Program of Nepal.

Results

Among 403 PLHIVs, tuberculosis was diagnosed in 40 (9.9%) individuals. Median age of the participants was 36 (30–43) years. Prevalence of TB was significantly higher among male PLHIVs than female PLHIVs (13.6% Vs 5.8%; P = 0.02) and Dalit ethnic group compared to Brahmin/Chettri (22.0%Vs5.9%, P = 0.01). The risk of developing TB was found significant among those with HIV stage progressed to WHO stage 3 and 4 (OR = 4.85, P<0.001) and with the family history of TB (OR = 4.50, P = 0.002).

Conclusions

Prevalence of TB among PLHIVs in Nepal was found 9.9%. Risk of developing TB was higher among PLHIVs who were male, Dalit, with HIV stage progressed to WHO stage 3 and 4 and with family history of TB. Hence, targeted interventions are needed to prevent the risk of developing TB among PLHIVs. Similarly, integrated, and comprehensive TB and HIV diagnosis and treatment services are needed for the management of TB/HIV co-infection in Nepal.

Progress of South East Asian Region countries towards achieving interim End TB strategy targets for TB incidence and mortality: a modelling study

OBJECTIVES

In 2018, the World Health Organisation (WHO) reported that almost 10 million people worldwide had tuberculosis (TB). The majority of the TB cases were concentrated in South East Asian Region (SEAR) countries. To curb this burden, the WHO has set interim targets to reduce TB incidence by 50% and mortality by 75% by 2025 (interim targets of the 'End TB' strategy). Hence, this study was conducted to determine the progress of SEAR countries towards reaching these interim targets for TB incidence and mortality.

METHODS

Secondary data analysis was performed using information from the WHO Global Health Observatory and Global Health Estimates for all SEAR countries. ARIMA modelling was used to forecast TB incidence and TB mortality from 2000 to 2025. Joinpoint regression was performed to determine the average annual percent change.

RESULTS

Based on the current trend, we estimated that the incidence and mortality of TB in SEAR countries will decline to 3.7 million (4.37 million in 2018) and 495,280 (650,979 in 2016) by 2025, respectively. Projected age-standardised TB incidence showed a significant decline in only four SEAR countries, with the maximal decline in Myanmar (47.3%) followed by India (23.4%) compared with 2015 estimates. Age-standardised TB mortality showed a declining trend in six SEAR countries, with the maximum decline found in Myanmar (60.3%) followed by Thailand (39.0%).

CONCLUSIONS

Current study findings show that it is highly unlikely for most SEAR countries to achieve the WHO recommended interim End TB targets of 50% reduction in incidence and 75% reduction in mortality by 2025.

Assessing Factors Associated with TB Awareness in Nepal: A National and Subnational Study

Tuberculosis (TB) has still remained a serious global health threat in low- and middle-income countries in recent years. As of 2021, Nepal is one of the high TB burden countries, with an increasing prevalence of cases. This study evaluates factors associated with TB awareness in Nepal. This study uses data from the Nepal Demographic and Health Survey, a cross-sectional survey carried out from June 2016 to January 2017. Multilevel logistic regression is performed to examine the association of demographic and socioeconomic factors with TB awareness. Our findings show a high level of TB awareness in all seven provinces of Nepal. Province 5 has the highest level of awareness (98.1%) among all provinces, followed by provinces 3 and 4, while province 6 has the lowest awareness level (93.2%) compared to others. Socioeconomic factors such as wealth, education and owning a mobile phone are significantly associated with TB awareness. Socioeconomic determinants are influential factors associated with TB awareness in Nepal. The wide variation in the proportion of awareness at a regional level emphasizes the importance of formulating tailored strategies to increase TB awareness. For instance, the use of mobile phones could be an effective strategy to promote TB awareness at a regional level. This study provides valuable evidence to support further research on the contribution of information and communication technology (ICT) usage to improving TB awareness in Nepal.

Status of rpoB gene mutation associated with rifampicin-resistant Mycobacterium tuberculosis isolated in a rural setting in Nepal

Mycobacterium tuberculosis ranks among the top 10 causes of deaths in Nepal despite the country having a long history of national tuberculosis prevention programmes that have proved very successful in the control of tuberculosis. Several cases of active or latent tuberculosis are still missing despite that the number of infected individuals is increasing each year. Microscopy has its own limitations and factors like low bacterial load, quality of sample, quality of smear, experience of microscopist etc. influence the overall sensitivity of the test. The implementation of a molecular technique-based rapid, point-of-care testing system offers higher sensitivity in the early diagnosis of tuberculosis. Cepheid GeneXpert is the most commonly used molecular technology in Nepal. It is a cartridge-based semi-quantitative, nested real-time PCR-based diagnostic system. It detects mutations in the beta-subunit of RNA polymerase (rpoB) gene that lead to rifampicin resistance (RR) in M. tuberculosis complex. The present study aims to increase our understanding of the epidemiology of mutations in the rpoB gene in tuberculosis-positive patients by using the Xpert MTB/RIF assay in a rural setting in Pyuthan Hospital, Nepal. Sputum from 2733 patients was tested for the diagnosis of tuberculosis using the Cepheid GeneXpert system between July 2018 and January 2020 at Pyuthan Hospital. Two hundred and ninety-seven of these samples (10.86 %) were positive for M. tuberculosis, of which 3.3 % (10/297) were rifampicin-resistant. Among rifampicin-resistant tuberculosis (RR-TB) patients, 50.0 % (5/10) showed mutations located in codons 529–533 (probe E) of the rpoB gene, followed by others. The GeneXpert system can be a convenient, highly sensitive, rapid and accurate tool for the diagnosis of tuberculosis, also identifying RR-TB and at the same time determining the molecular epidemiology of rifampin resistance-associated mutations in rural and/or resource-limited laboratory settings.

Knowledge on tuberculosis and utilization of DOTS service by tuberculosis patients in Lalitpur District, Nepal

BACKGROUND

Tuberculosis is one of the major infectious diseases and is both complex and serious. It is spread from person to person through the air, causing a public health burden, especially in low- and middle-income countries. This study aims to assess the knowledge on tuberculosis and the utilization of Directly-Observed Therapy, Short Course (DOTS) service from the public DOTS centers in Lalitpur district of Nepal.

METHOD

A structured questionnaire was used to collect data from 23 DOTS centers in Lalitpur district. Univariate and multivariate logistic regression was applied to assess the knowledge on tuberculosis and utilization of DOTS among people living with tuberculosis.

RESULTS

Among 390 respondents, 80% of patients had knowledge of tuberculosis and 76.92% utilized the DOTS service from the DOTS center. People of higher age (50-60 years) [aOR; 13.96, 95% CI 4.79,40.68], [aOR; 10.84,95% CI 4.09,28.76] had significantly more knowledge on TB and utilization of the DOTS service compared to the younger group. Additionally, those who completed twelfth class [aOR; 2.25, 95% CI 0.46,11.07] and [aOR;2.47, 95% CI 0.51,11.28] had greater knowledge of Tuberculosis and utilization of DOTS compared to those who had not completed twelfth class. Likewise, compared to urban residents, respondents in rural areas (aOR; 0.51, 95% CI 0.27,0.97) had less knowledge of tuberculosis, (aOR; 0.57, 95% CI 0.32,1) and less chance of utilization of the DOTS service from the DOTS center.

CONCLUSION

Approximately one quarter of patients did not have adequate knowledge of tuberculosis and were not utilizing the DOTS service, particularly in younger age groups, people living in a combined family, with no education, poor economic position, and from rural areas. Findings of this study revealed that some specific programs are needed for enhancing the knowledge and utilization of DOTS, particularly for those patients whose economic situations extended from low to mid range.

Pulmonary tuberculosis at Patan Hospital, Nepal: One year audit

Background

Globally, Tuberculosis (TB) is one of the top 10 causes of death. In Nepal, poverty and malnutrition aggravate the burden of TB. To identify Mycobacterium tuberculosis sputum is the best sample to identify the bacterium which is helpful for diagnosis. The aim of this study is to identify the situation, burden and challenges of pulmonary tuberculosis in low-middle income country like Nepal.

Method

A retrospective-audit with reliable-secondary-data of one year was collected (n = 4131). Descriptive-analysis was performed using frequency, percentage and analytical using chi-square-test. Level of significance was set at p < 0.05. Ethical Approval was obtained from IRC-PAHS.

Result

The prevalence of notified/suspected cases was highest among the patients having >60 years of age 1344(32.54%) and least among the patients with ≤15 years of age 239(5.79%). The male had 1.67 times more smear-positive pulmonary TB cases. Among the AFB-positive cases, smear 3+ was seen in most of the cases 69(38.54%) followed by smear 1+ and smear 2+ in 56(31.28%) and 54(30.16%) respectively.

Conclusion

The prevalence of smear-positive pulmonary TB case is higher in male. Smear 3+ is seen in most of the followed by smear 1+ and smear 2+. The Burden of Pulmonary TB is more among adult and old-age-people and its control is a challenge for developing and low-middle income countries like Nepal.

Multi-spectral Pattern of Clinical Presentation and the Resultant Outcome in Central Nervous System Tuberculosis: A Single Center Study on the Ubiquitous Pathogen

Central nervous system (CNS) tuberculosis (TB) is a great medical masquerader having a multi-spectral pattern of clinical presentation, thereby complicating early diagnosis and appropriate management. This review article describes clinical presentation of CNS TB in a group of 47 patients, who were managed in the Nobel Medical College and Teaching Hospital in Biratnagar, Nepal during the last 2 years. We evaluated demographic profile, mode of management, and clinical outcome in these patients. The findings were that intracranial TB was present in 27 (57.5%) patients and the spinal involvement was in 20 (42.5%) patients. The most frequent presentation of the former was TB meningitis with hydrocephalus (55.5%) and that of the latter was Pott's spine with abscess in 50% of cases. TB meningitis with hydrocephalus was the commonest cause of mortality (83.3%) among the patients. CNS TB should be considered in the differential diagnosis in patients presenting with equivocal neurological signs and symptoms, especially in TB endemic regions. It seems prudent to commence early antitubercular therapy for safeguarding such patients from poor neurological outcome as well as mortality it harbingers.