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BackgroundIdentifying 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.MethodsA 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.ResultsThe 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.ConclusionTotal 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.

ObjectiveThe aim of this study was to describe treatment outcomes for multi-drug resistant tuberculosis (MDR-TB) outpatients on a standardized regimen in Nepal.MethodologyData on pulmonary MDR-TB patients enrolled for treatment in the Green Light Committee-approved National Programme between 15 September 2005 and 15 September 2006 were studied. Standardized regimen was used (8Z-Km-Ofx-Eto-Cs/16Z-Ofx-Eto-Cs) for a maximum of 32 months and follow-up was by smear and culture. Drug susceptibility testing (DST) results were not used to modify the treatment regimen. MDR-TB therapy was delivered in outpatient facilities for the whole course of treatment. Multivariable analysis was used to explain bacteriological cure as a function of sex, age, initial body weight, history of previous treatment and the region of report.Principal FindingsIn the first 12-months, 175 laboratory-confirmed MDR-TB cases (62% males) had outcomes reported. Most cases had failed a Category 2 first-line regimen (87%) or a Category 1 regimen (6%), 2% were previously untreated contacts of MDR-TB cases and 5% were unspecified. Cure was reported among 70% of patients (range 38%–93% by Region), 8% died, 5% failed treatment, and 17% defaulted. Unfavorable outcomes were not correlated to the number of resistant drugs at baseline DST. Cases who died had a lower mean body weight than those surviving (40.3 kg vs 47.2 kg, p<0.05). Default was significantly higher in two regions [Eastern OR = 6.2; 95%CL2.0-18.9; Far West OR = 5.0; 95%CL1.0-24.3]. At logistic regression, cure was inversely associated with body weight <36 kg [Adj.OR = 0.1; 95%CL0.0-0.3; ref. 55–75 kg] and treatment in the Eastern region [Adj.OR = 0.1; 95%CL0.0-0.4; ref. Central region].ConclusionsThe implementation of an ambulatory-based treatment programme for MDR-TB based on a fully standardized regimen can yield high cure rates even in resource-limited settings. The determinants of unfavorable outcome should be investigated thoroughly to maximize likelihood of successful treatment.

The drug-induced hepatotoxicity is a signifi cantly increasing problem worldwide, but it is of more concern in the treatment of tuberculosis (TB) infection, especially in a third world country like Nepal, where tuberculosis is still endemic. Liver has a central role in drug metabolism and detoxifi cation, and is consequently vulnerable to toxic effects of the drugs. The study was carried out from August 2006 to May 2007. The ATT patients, who visited the chest clinic, were sent to the laboratory for analysis of Liver enzymes (ALT, AST) and bilirubin level. During the period of August 2006 to May 2007 total of 114 patients; 114 blood samples were collected for liver enzymes analysis. It was found that among114 ATT patients; 41 patients (35.0%) had abnormal parameters with the elevation of serum bilirubin level, AST level and ALT level. It showed that drug induced hepatotoxicity due to anti TB drugs is relatively higher rate among lower socio-economic status group. Out of 114 cases, the marked elevation of total bilirubin level (>5.0mg/dl) was found in 15 (13.0%) and mild elevation of bilirubin level (1.1-5.0mg/dl) was found in 25 (22.0%) patients while 74 (65.0%) patients were found to have normal level of bilirubin. Similarly, 17 (15.0%) patients were found to have moderate elevation of ALT level (above 51.0IU/L), 5 (4.0%) patients were found to have slight elevation of ALT level (36-50IU/L) and 92(81.0%) patients had normal level. Likewise 10 (9.0%) patients were found to have moderate elevation of AST level (above 51.0IU/L); 8 (7.0%) had slight elevation of AST level (41-50 IU/L); and 96 (84.0%) were found to have normal level. The facts associated behind these fi ndings are probably poverty, malnourishment, alcohol consumption, illiteracy of people and poor health management system. Hence, for the treatment of TB , with ATT regimens, a baseline laboratory testing and monitoring system should be adopted before starting treatment which might help to reduce drug induced hepatotoxicity in ATT patients.

Tuberculosis (TB) is a leading public health problem worldwide particularly in the developing countries. The HIV epidemic has increased the global tuberculosis burden. Estimating the proportion of HIV infection among TB cases can act as early warning system for the spread of TB due to HIV in the country. The objective of the study was to know status of TB/HIV co-infection cases among the TB patients at DOTS clinic in BPKIHS, Dharan, Nepal. Three Hundred newly diagnosed TB cases attended to BPKIHS DOTS clinic were tested for HIV. Among 300 newly TB patients, 14 (4.7%) patients were HIV positive. All were males. The study has shown very high (4.7%) TB/HIV co-infection. This is an alarming situation. Similar operational research can be conducted in different parts of Nepal to know the exact scenario of TB/HIV co-infection, which is necessary for formulating national policy & guidelines for TB/HIV control in the country. Keywords: TB & HIV Co-infection; TB; HIV; Nepal DOI: 10.3126/saarctb.v5i2.3072 SAARC J. Tuber. Lung Dis. HIV/AIDS 2008 Vol.5(2) 22-25