ABSTRACT
SETTING: A tuberculosis programme run by a non-governmental organisation in eight hill and mountain districts of eastern Nepal. OBJECTIVE: To assess the impact of contact screening on case-finding. DESIGN: A retrospective cohort study of contacts of smear-positive, smear-negative and extra-pulmonary tuberculosis patients diagnosed and registered during 1996-1998 ('index cases'). Contacts, defined as household members identified by index cases, were screened by sputum examination; two positive smears were taken to indicate smear-positive pulmonary disease. RESULTS: Approximately 50% (668) of registered cases identified contacts; 75% (2298) of the contacts identified provided one or more sputum specimens. An overall smear-positive case yield of 0.61% (14) was obtained from contacts tested, all except one of which were contacts of smear-positive index cases. For smear-positive index cases with a smear grading of > or = 2+, the yield was 7.2 times greater (P = 0.04) than for those with a grading of 1+. CONCLUSION: In this setting, sputum examination of household contacts of smear-negative and extrapulmonary tuberculosis cases is not justified. Further assessment is needed to evaluate the utility of testing contacts of smear-positive cases without symptom screening, and whether cost effectiveness can be improved by restricting testing to contacts of cases with high bacterial (> or = 2+) loads.
Subject(s)
Contact Tracing , Mass Screening , Tuberculosis, Pulmonary/diagnosis , Cohort Studies , Developing Countries , Health Policy , Humans , Nepal , Program Evaluation , Retrospective Studies , Tuberculosis, Pulmonary/transmissionABSTRACT
To establish the role of home visiting in an NGO-run tuberculosis control programme in Nepal, information was collected on home visits to a cohort of 205 smear-positive patients. Almost one third of new smear-positive cases were visited, either for treatment initiation (n = 33) or for retrieval following non-attendance (n = 29); thus 14% of patients required a home visit to ensure treatment completion. It is unlikely that the WHO-recommended target of 85% cure rate would be achieved without defaulter tracing, although a further study comparing home visiting against no visiting would be necessary to assess the contribution that this activity makes to improving treatment outcomes.
Subject(s)
Disease Outbreaks/prevention & control , House Calls/statistics & numerical data , Rural Health Services/organization & administration , Tuberculosis/epidemiology , Antitubercular Agents/administration & dosage , Cohort Studies , Communicable Disease Control/methods , Evaluation Studies as Topic , Female , Humans , Isoniazid/administration & dosage , Male , Nepal/epidemiology , Program Development , Program Evaluation , Thioacetazone/administration & dosage , Treatment Outcome , Tuberculosis/drug therapyABSTRACT
SETTING: A tuberculosis programme in hill and mountain districts of Nepal supported by an international non-governmental organisation (NGO). OBJECTIVE: To evaluate under programme conditions the effectiveness of unsupervised monthly-monitored treatment using an oral short-course regimen. DESIGN: In this prospective cohort study, outcomes for new cases of smear-positive tuberculosis starting treatment over a two-year period in four districts in which a 6-month rifampicin-containing regimen was introduced as first-line treatment (subjects) were compared to outcomes for similarly defined cases in four districts where a 12-month regimen with daily streptomycin injections in the intensive phase continued to be used (controls). RESULTS: Of 359 subjects started on the 6-month regimen, 85.2% completed an initial course of treatment compared to 62.8% of 304 controls started on the 12-month regimen (P < 0.001); 78.8% of subjects and 51.0% of controls were confirmed smear-negative at the end of treatment (P < 0.001). The case-fatality rate during treatment was 5.0% among subjects and 11.2% among controls (P = 0.003). Among those whose status was known at two years, 76.9% of subjects were smear-negative without retreatment, compared to 60.9% of controls (P < 0.001). CONCLUSION: In an NGO-supported tuberculosis control programme in remote districts of Nepal, patient-responsible short-course therapy supported by rapid tracing of defaulters achieved acceptable outcomes. Where access and health care infrastructure are poor, district-level tuberculosis teams responsible for treatment planning, drug delivery and programme monitoring can be an appropriate service model.
