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.

Knowledge, Attitude, and Practices on Drug-Resistant Tuberculosis Infection Control in Nepal: A Cross-Sectional Study.

Drug-resistant tuberculosis (DR-TB) transmission is an important problem, particularly in low-income settings. This study is aimed at assessing the knowledge, attitude, and practices of DR-TB infection control among the healthcare workers under the National Tuberculosis Control Program in Nepal. In this cross-sectional study, we studied the healthcare workers from all the 11 functioning DR-TB treatment centers across Nepal in March 2018. Through face-to-face interviews, trained data collectors collected data on the characteristics of healthcare workers, their self-reported knowledge, attitude, and practice on DR-TB infection control. We entered the data in Microsoft Excel and analyzed in the R statistical software. We assigned a score of one to the correct response and zero to the incorrect or no response and calculated a composite score in each of the knowledge, attitude, and practice domains. We ascertained the healthcare workers as having good knowledge, appropriate attitude, and optimal practices when the composite score was ≥50%. We summarized the numerical variables with median (interquartile range (IQR)) and the categorical variables with proportions. We ran appropriate correlation tests to identify relationships between knowledge, attitude, and practice scores. We regarded a p value of <0.05 as significant. A total of 95 out of 102 healthcare workers responded. There were 46 male respondents. The median age was 33 years (IQR 26-42). Most of them (53, 55.79%) were midlevel paramedics. We found 91 (95.79%) respondents had good knowledge, 49 (51.58%) had an appropriate attitude, and 35 (36.84%) had optimal practices on DR-TB infection control. We found a statistically significant positive correlation between attitude and practice scores (ρ = 0.37, p ≤ 0.001). The healthcare workers at the DR-TB treatment centers in Nepal have good knowledge of DR-TB infection control, but it did not translate into an appropriate attitude or optimal practices.

Prevalence and risk factors of depression in patients with drug-resistant tuberculosis in Nepal: A cross-sectional study.

BACKGROUND: Patients with drug-resistant tuberculosis (DR TB) have a protracted course of illness and the available treatment has a low success rate. These factors combined with the associated stigma and financial implications put the patients with DR TB at an increased risk of depression. The psychiatric side effects of anti-tuberculosis drugs further aggravate the problem. This study aimed to estimate the prevalence of depression among patients with DR TB in Nepal and identify risk factors. METHODS: We conducted this cross-sectional study in April 2018 at all the functioning 11 programmatic DR TB treatment centers across Nepal. We selected 129 patients aged ≥ 16 years receiving treatment for DR TB by non-probability quota sampling. Six trained data collectors conducted face-to-face interviews and administered the Nepali language version of Patient Health Questionnaire 9 (PHQ-9) to screen for depression. We summarized sociodemographic and treatment characteristics with median (Interquartile Range [IQR]) and proportions as appropriate. We performed univariate analysis for the variables hypothesized as risk factors for depression. We fitted a multivariable binary logistic regression model with depression as the outcome variable and the variables with a significance level of < 0.25 as explanatory variables. We regarded a p-value of < 0.05 as significant for individual variables in the logistic regression model. RESULTS: Of the 129 patients studied, 92 (71.3%) were male and the median age was 36 years (IQR 25-48). The majority (109, 84.4%) had multi-drug resistant tuberculosis (MDR TB). We identified 81 patients (62.7%, 95% Confidence Interval [CI] 53.7-71) with the PHQ-9 score of 10 or more signifying probable depressive disorder. In univariate analyses, age, treatment center location, DR TB treatment duration, and duration of current illness had a p-value lower than the pre-specified cut-off of 0.25. In the multivariable logistic regression model, we found a statistically significant association of depression with the duration of illness (adjusted Odds Ratio 1.15, 95% CI 1.07-1.26, p < 0.001). CONCLUSION: This study has found that a large proportion of the patients with DR TB screened have depression suggesting the need for screening and management of comorbid depression within the National TB Control Program.

Prevalence of Human Immunodeficiency Virus Infection among Tuberculosis Patients in Nepal.

BACKGROUND: National Tuberculosis Program has envisioned to provide human immunodeficiency virus testing for all tuberculosis patients. However, human immunodeficiency virus testing coverage among notified tuberculosis patients is very low in Nepal. Hence, it is difficult to reflect the prevalence of human immunodeficiency virus infection among Tuberculosis patients based on the information available from the routine system. Hence National Tuberculosis Program carried out sentinel surveillance to assess the prevalence of human immunodeficiency virus infection among tuberculosis patients and its associated factors in Nepal. METHODS: This study is cross-sectional study type conducted at six sentinel sites across the country. This study lasted for six months starting from March 2017 to August 2017. The sample size was calculated using Epiinfo STATCAL application assuming confidence interval at 95%, 85% power and 5% non-response rate. The required sample size was 1672 tuberculosis patients. Ethical approval was obtained from Nepal Health Research Council. All types of tuberculosis patients who were equal or above 15 years were included in the study. Human immunodeficiency viruse testing was performed among tuberculosis patients as per the testing algorithm recommended by national guideline. RESULTS: The study was carried out among 1664 tuberculosis patients registered for tuberculosis treatment during the study period. More than two thirds of tuberculosis patients (67%) were male. The median age of tuberculosis patients was found 32 years. During human immunodeficiency virus testing, 41 out of 1664 tuberculosis patients were found human immunodeficiency virus positive resulting human immunodeficiency virus infection seroprevalence among tuberculosis patients to 2.5%. Prevalence of human immunodeficiency virus infection was significantly associated with age (P=0.002), caste/ethnicity (P=0.025), religion (P=0.015) and occupation (P=0.014) of tuberculosis patients. CONCLUSIONS: Prevalence of human immunodeficiency virus infection among tuberculosis patients was found 2.5%. Information and access to tuberculosis/human immunodeficiency virus services needs to be increased toaddress tuberculosis-human immunodeficiency virus co-infection in Nepal.

Delay in the diagnosis of tuberculosis in Nepal.

BACKGROUND: Identifying reasons for delay in diagnosis and treatment of tuberculosis is important for the health system to find ways to treat patients as early as possible, and hence reduce the suffering of patients and transmission of the disease. The objectives of this study was to assess the duration of delay in the diagnosis of tuberculosis and to investigate its determinants. METHODS: A cross-sectional survey was conducted using a structured questionnaire in 307 new tuberculosis patients registered by the National Tuberculosis Programme (NTP) in all DOTS centres in Banke district of Nepal. RESULTS: The median patient delay was 50 days, the median health system delay was 18 days, and the median total delay was 60 days. Sputum smear negative participants had significantly lower risk of patient delay. Smokers using >5 cigarettes per day had higher risk of patient delay and health system delay. CONCLUSION: Total delay in the diagnosis of tuberculosis in Banke district is shorter compared to other places in Nepal and neighbouring countries. The shorter delay for smear negative pulmonary tuberculosis raises suspicion that many of these patients are not examined according to the NTP manual before being diagnosed. Increasing public awareness of the disease and expansion of the facilities with assured quality could be helpful to reduce the delay in the diagnosis of tuberculosis.