Access of Key Population to Available HIV and TB Services in Nepal: A Cross Section Study

Introduction: TB is considered one of the opportunistic infection among PLHIV. The increasing burden of HIV/TB co-infection among key population cause problem to maintain adherence to ART and DOTS services. The emergence of MDR-TB is one of the greatest challenge to control and management of both diseases. However, having knowledge and information of both diseases are important role to access the available HIV/TB services. Methods: A cross-sectional survey was conducted among key population who had HIV/TB co-infection in two-epidemic zone of Nepal. A pretested semi-structured questionnaire was used to collect data. ANOVA test was done to analyze the collected data by using SPSS version 20.0. Results: A total of 343 HIV/TB co-infected individuals were enrolled to the study. Most of participants were from ART and DOTS clients. Therefore, the study found that there was significance difference found between knowledge about TB (F=4.400, p= 0.005), causative agent of TB (F=3.160, p=0.025), risk of TB illness among PLHIV (F=8.491, p=0.001) and among key affected population. Moreover, there was significance difference found between access to OI treatment (F=5.113, p=0.002) and access to viral load (F=4.642, p=0.003) among key study population. In gender perspective, there was no significance difference to use and access to available HIV/TB services. Conclusion: The general knowledge on HIV/TB co-infection was significant association with key population. The knowledge on HIV/TB and access to NGOs’ help can significant effect to access the available HIV and TB services.

An Observational Study of Follow Up of MDR Tuberculosis Patients after Successful Completion of Category 4 Treatment under RNTCP (PMDT) in Allahabad District

Introduction: Drug-resistant TB is a persistent threat, with 490 000 million cases of multidrug-resistant TB emerging in 2016.The countries with the largest numbers of MDR/RR-TB cases were China, India and the Russian Federation. Given the prolonged nature of MDR-TB, one might expect higher rates of chronic disability among cured patients with MDR-TB. To explore these questions, we conducted an observational study focusing on: clinical, bacteriological, biochemical and various health parameter status of successfully treated MDR-TB patients. Methods: Subjects enrolled in study as per inclusion and exclusion criteria were assessed by recording of demographic data and were subjected to a predetermined set of questions for determining the history of previous anti tubercular treatment and exposure to various type of risk factor for development of MDR TB. Physical parameters of health were determined and recorded. Results: Total of 84 patients were enrolled in our study (57-males, 27 females).69 subjects (46-males, 23-Females) were found apparently healthy. 25 subjects migrated outside.6 patients (male-6, Female-2) died.7 patients were diagnosed as XDR-TB (5-Males,2-Females).34 subjects (18- males, 16-females) (44.73%) were very under weight. Total 13 (Males-12, Females-1) out of 76 subjects (17.10%) were under weight. Mid arm circumference (MAC) of 35 out of 76(21- males, 18-females) subjects (46.05%) was below 5th percentile. Majority of subjects showed moderate & severe obstruction in PEFR. Conclusion: This study shows that the community based standardized treatment regimen is effective as only one of the patients was bacteriologically positive on follow up. However, significant numbers of treated MDR-TB patients suffer from clinical, nutritional and functional post-treatment adverse events leading to some morbidity.

Epidemiology of Drug Resistant Tuberculosis in Samtse General Hospital, Bhutan: A Retrospective Study

Introduction: Multidrug resistant tuberculosis (MDR-TB) is defined as a case of tuberculosis resistant to rifampicin and isoniazid which are the first line anti tuberculosis drugs. Globally emergences of MDR-TB possess a challenge to TB control. In Bhutan, the proportion of MDR-TB is high at par with the global level. This study will explore the predictors of MDR-TB and the trend at Samtse General Hospital which has high burden of tuberculosis. Methods: This was a retrospective cross sectional study. The data was extracted from TB treatment cards maintained at TB unit of Samtse General Hospital TB from January 2012 to June 2018. Results: The study showed the prevalence of drug resistant to at least one drug at 21% and MDR-TB prevalence at 16%. The patients with previous treatments (AOR: 4.59; 95% CI .03-.18) and patients under the age of 30 years (AOR: 2.7; 95% CI 1.01- 7.42) were significantly associated with MDR-TB. Conclusion: This study shows high prevalence of MDR-TB in Samtse. Better strategies and concrete actions need to be developed to combat the increase of MDR-TB.

HIV Vulnerability and Sexual Risk Behaviour of the Drayang Girls in Bhutan

Introduction: The rapid socio-economic development in Bhutan has brought changes in individual lifestyles resulting in increased risk behavior of the urban population, particularly the Drayang girls. This study investigated the underlying factors influencing the sexual risk behaviour of Drayang girls and their vulnerability to HIV and Sexually Transmitted Infection (STI). The Drayangs are dance bars in Bhutan where the women perform Bhutanese songs/dances on the stage to entertain the bar patrons and making them pay for their performance. Methods: This is a cross-sectional descriptive study conducted from May-July 2015 in three urban districts (Thimphu, Paro, and Phuentsholing) of Bhutan. The convenient non-random sampling method was used to recruit the respondents. We have collected the data using structured questionnaires including the taking of blood samples for HIV, Hepatitis B, and Syphilis testing. Results: Of the 245 Drayang girls recruited for this study, 28.2% have engaged in transactional sex and 71.8% in non-transactional sex within last month. Condom use during transactional sex was 36.2% and non-transactional sex was 21.6%. The prevalence of HIV was 0.82%, hepatitis B 6.9%, and syphilis 2.8%. The factors such as marital status (divorced and unmarried), living arrangements, current living cities, and alcohol consumption were significantly (p<0.05) associated with transactional sex among Drayang girls. Conclusion: Although the prevalence of HIV and STIs is low among the Drayang girls, the presence of high riskbehavior with low condom use still makes them vulnerable to HIV and STIs. The study recommends putting more effort in prevention of HIV and STI by increasing awareness of HIV and STI, targeted interventions like Behaviour Change Communications (BCC), condom promotion, condom negotiation skills and access for testing and treatment of HIV and STI.

Comparative Study of Pulmonary and Extra-Pulmonary Tuberculosis in Bhutan (2015-2017)

Introduction: Extrapulmonary Tuberculosis (EPTB) has been increasingly diagnosed and reported compared to Pulmonary TB (PTB) in Bhutan in the recent years. In this comparative study, our study describes the epidemiology, diagnostic modalities used, inconsistency in case-classification and treatment outcomes of PTB and EPTB cases diagnosed from 2015-2017. Methods: A retrospective descriptive study was conducted by retrieving patient records maintained at the 11 TB Reporting Centres. Using two stage cluster sampling technique, nine primary sampling units (9-PSUs) were generated for the years 2015, 2016 and 2017 respectively. Based on the highest caseloads among 32 TB Reporting Centres, nine primary clusters were selected first and final sample of 350 for each year were drawn using systematic random sampling technique from the PSUs. Results: We recruited a total of 1048 cases (PTB=555, EPTB=493) in the final descriptive analysis. The median age of the subjects was 27 years (range 1-87) with slight female predominance (53%). Students were the highest (23.85%) followed by farmers (17.94%). The proportion of PTB was (52.95%), EPTB of (47.08%) and clinically diagnosed EPTB accounted for (92%), which is extremely high. Twelve miliary/disseminated TB cases (1.15%) were miss-classified as EPTB and (56%) EPTB cases were not classified based on the body sites involved. The overall treatment success rate (TSR) of PTB and EPTB was (93.26%). Conclusion: We recommend an expert team to revisit National TB treatment guidelines on diagnosis of EPTB and ensure EPTB site/s are properly identified and documented. Sensitize clinicians and other units (ENT, Surgery, Orthopedics, MCH, General OPD etc.) on the referral of EPTB cases to Medical Specialist/Chest Physician for consultation.

Editorial Vol.17(1)

On 26th September 2018, Heads of States of different countries gathered at the United Nation General Assembly for the first-ever UN High-Level Meeting (HLM) on tuberculosis (TB) to accelerate efforts in ending TB. The theme of the meeting was “United to end tuberculosis: an urgent global response to a global epidemic”. This was a landmark opportunity to marshal the political will and resources to end TB. Together we can defeat TB and overcome antimicrobial resistance by closing the funding gap for TB research and product development through equitable approaches, securing universal access to new medicines and fostering global collaboration. TB is an infectious disease with high mortality, the most common form of antimicrobial resistance and leading cause of death in people living with HIV/AIDS. World Health Organization declared TB as global emergency. Still, TB is second leading cause of death worldwide. A good percentage of people in the developing countries continue to suffer from this menace because of poverty, gender inequality, vulnerability, discrimination and marginalization. Millions of people with TB do not have access to quality care, including affordable diagnostic test and treatment facility and is a precarious challenge to end TB globally, as well as in SAARC Region. It is estimated that one quarter of the world’s population is infected with TB bacteria. SAARC Region has 36% of the global TB burden with 3.7 million new TB cases and 0.5 million death. Moreover these morbidity and mortality occur mainly in the economically productive age groups of 15-49 years. In order to eliminate TB from the SAARC Region before the global target, the SAARC TB and HIV/AIDS (STAC) has revised “SAARC Regional Strategy on Elimination of Tuberculosis (2018-2023)”. This year the world TB day theme was “Its time”. So it is time to involve policy makers to advocate and take active participation in the TB control programmes. The affected and infected people with this disease can bring positive changes by combining their voices towards the elimination of the disease. Now it is time to intensify advocacy, social mobilization, partnership, research and inter-sectoral efforts to achieve the global target of ending the TB epidemic by 2030. Chief Editor Director, STAC

Tuberculosis in Nepal: Situation, Challenges and Ways Forward

Introduction: Globally, tuberculosis is a major public health problem. Moreover, the emergence of drug resistant forms of TB has threatened TB prevention and treatment efforts. Despite the long history of tuberculosis prevention efforts, tuberculosis still ranks among the top ten causes of deaths in Nepal. Furthermore, Nepal being land locked with two high TB burden countries i.e. India and China, it has added difficulties to National Tuberculosis program. Hence this study aims to review the situation of National Tuberculosis Program in Nepal and explore the possible challenges and ways forward for NTP to strengthen the TB diagnostics and treatment services in Nepal. Methods: This study is based on the review of available literatures and data sources related to tuberculosis prevention, care and control. Secondary data published by National Tuberculosis Program in the annual report for the year 2015, 2016 and 2017 were considered for the situation analysis of tuberculosis in Nepal. We used different platforms like Google scholar, PubMed to search relevant literatures. Results: This has been a huge gap between WHO TB estimates and TB cases notification by the national system. It was 22% in 2015, 27% in 2016 and 29% in 2017. However National Tuberculosis Program has maintained treatment success rate consistently above 90%. Tuberculosis program has yet not achieved universal HIV testing, although HIV testing among TB patients has increased rapidly. Similarly, only 75%, 1994 received DST out of 2601 retreatment TB cases have received DST in 2017 despite guideline suggest mandatory drug susceptibility testing for retreatment TB cases. Conclusion: Case notification has reduced gradually. It is difficult to achieve the target envisioned by NSP 2016-21 if the current case notification trend persists. NTP needs to expand service sites ensuring minimum quality standards as well as scale up targeted intervention addressing human right issues to identify the missing TB cases. NTP needs to regulate the quality of diagnosis and treatment TB services offered by private sector.

Case Series of Pott’s Spine Diagnosed by ZN Stain and BacTec MGIT in a Tertiary Care Hospital

Introduction: Pott’s spine is a destructive form of tuberculosis and accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal Tuberculosis is most often missed due to inadequate sample and lack of clinical history. Most of the Extrapulmonary tuberculosis (EPTB) can be diagnosed by Ziehl Nelson stain (ZN) only, when clinically suspected samples are adequate and optimally stained. We are reporting four case series of spinal tuberculosis diagnosed by ZN stain and confirmed by Bactec MGIT Culture. Material & Methods: These four clinically suspected spinal biopsis were received for ZN stain and MTB culture by MGIT. Results: All the four spinal biopsies were found positive by ZN stain as well as by BacTec MGIT.All the four cases were HIV negative. ESR and CRP of all four cases were raised. Discussion & Conclusion: Spinal tuberculosis can be easily diagnosed by ZN stain in resource constraint lab. Despite its common occurrence and the high frequency of long-term morbidity, there are no straight forward guidelines for the diagnosis and treatment of spinal tuberculosis. Early diagnosis and prompt treatment is necessary to prevent permanent neurological disability and to minimize spinal deformity.

Editorial Vol.16(2)

No abstract available

Proteomic profile of pulmonary and extra pulmonary TB samples

Introduction: Tuberculosis (TB) is a major health problem in India, so early diagnosis and treatment of Mycobacterium tuberculosis (M.tb.) infection can prevent deaths from this pathogen. The secretion of proteins by M.tb. is important in diagnostic purposes for generation of therapeutic drugs and vaccines candidates for TB. The objective of this study was to identify the protein expression (biomarkers) in TB and Tuberculosis meningitis (TBM) using proteomic approach. Methods: In this study, using Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDSPAGE), we analyzed the secretory proteins of M.tb. in serum, cerebrospinal fluid (CSF) samples. The identified proteins were determined by Total Lab- 100 Quantity One densitometry software. Results: Our study showed that protein bands expressed in CSF samples reveals the presence of 72kD, 70kD, 44kD, 40kD & 16kD predominantly in TBM patients compared to healthy individuals. The electrophoretogram identified 97kD, 72kD, 44kD, 38kD, 29kD & 16kD predominant proteins in serum samples of TB patients. Conclusion: The detection of secretory proteins in serum and CSF samples of M.tb. in TB and TBM patients gives reliable and early diagnosis of TB and TBM. The secretory proteins can be useful as immunodiagnostic and vaccine targets which can serve as important biomarkers