IMPLEMENTATION ADHERENCE OF CONTACT TRACING FOR DRUG RESISTANCE TUBERCULOSIS UNDER THE NATIONAL TUBERCULOSIS PROGRAM IN NEPAL

Poudel, Shiva, dr. Yodi Mahendradhata, MSc., PhD., and Dr. Dra. Ning Rintiswati, M.Kes.

2021 | Tesis | MAGISTER ILMU KESEHATAN MASYARAKAT

Tuberculosis (TB) is a communicable disease and one of the top ten leading causes of death worldwide. TB is a major public health problem in Nepal affecting thousands of people each year. It is the seventh leading cause of death in Nepal. The Drug Resistance Survey (2011-12) found that burden of drug resistant forms of TB was increasing, with 9.3 percent of new patient were found resistant to at least one anti-tuberculosis drug. The emergence of resistance to anti-tuberculosis drugs, and particularly of Multidrug-Resistant Tuberculosis (MDR-TB) is a serious public health threat and an obstacle to effective global TB control. Contact tracing of MDR-TB patients is highly recommended by the World Health Organization. The purpose of contact investigation is to promptly identify the tuberculosis cases earlier, start to treat individuals with active or latent TB, stopping TB transmission further from index cases in the community and enhance the active case finding. Aim of the study was to assess implementation adherence of contact tracing among DR TB in Nepal. Study also explored the existing implementing coverage and factors affecting the implementation adherence to contact tracing in term of enablers and barriers of CT among DR TB close contacts. Study adopted sequential explanatory study (quantitative study followed by qualitative study) mixed method and implementation research design using purposive, maximum variance. For quantitative data collection, DR TB register was reviewed to track the information on contact tracing of household members of index DR TB cases within past one year. Similarly, for qualitative data collection key informant interview of VCT, health care providers, district TB focal person, and provincial health officers was collected on DR TB contact tracing and factors related to implementation adherence and determinants of the program. Further, client exit interview from DR center was conducted to assess the further information on adherence of contact tracing from patients and their family members perspective. Total 28 participants were interviewed from two districts. Similarly, secondary data of all DR patient from past one year were extracted using data extraction checklist. More than two third (69%) of the family member of the DR TB had participated for at least one time contact tracing throughout their treatment period until the study was conducted. Two new cases of TB were diagnosed from 47 presumptive TB cases who were in close contact with index DR TB patients As per the assumption criteria for adherence that I have kept in the study, health workers and VCT adherence to CT guideline among DR TB close contacts standard operation procedures is found to be medium. Study explores different barrier and facilitators for conducting CT among DR TB close contacts. Insufficient infrastructure, CT limited to household member only, lack of adequate training and orientation and persistent stigma were identified as major barrier for conducting CT. Likewise changing perception on TB and towards CT, incentive for health workers and VCT for conducting CT and use of local health workers to conduct CT, are major factors that are acting as facilitator to conduct CT. Contact tracing activities for DR TB close contact program is being implemented with real field based practical and resource limited setting. Study suggests expanding the boundary of conducting CT beyond family to social contact, to increase efforts on advocacy and lobbying of CT among the periphery health workers, provision of separate CT staff, expanding the DR centers and Gene Xpert centers to periphery health institution and empower the staff by providing training to increase the coverage and adherence of CT among DR TB contacts.

Tuberculosis (TB) is a communicable disease and one of the top ten leading causes of death worldwide. TB is a major public health problem in Nepal affecting thousands of people each year. It is the seventh leading cause of death in Nepal. The Drug Resistance Survey (2011-12) found that burden of drug resistant forms of TB was increasing, with 9.3 percent of new patient were found resistant to at least one anti-tuberculosis drug. The emergence of resistance to anti-tuberculosis drugs, and particularly of Multidrug-Resistant Tuberculosis (MDR-TB) is a serious public health threat and an obstacle to effective global TB control. Contact tracing of MDR-TB patients is highly recommended by the World Health Organization. The purpose of contact investigation is to promptly identify the tuberculosis cases earlier, start to treat individuals with active or latent TB, stopping TB transmission further from index cases in the community and enhance the active case finding. Aim of the study was to assess implementation adherence of contact tracing among DR TB in Nepal. Study also explored the existing implementing coverage and factors affecting the implementation adherence to contact tracing in term of enablers and barriers of CT among DR TB close contacts. Study adopted sequential explanatory study (quantitative study followed by qualitative study) mixed method and implementation research design using purposive, maximum variance. For quantitative data collection, DR TB register was reviewed to track the information on contact tracing of household members of index DR TB cases within past one year. Similarly, for qualitative data collection key informant interview of VCT, health care providers, district TB focal person, and provincial health officers was collected on DR TB contact tracing and factors related to implementation adherence and determinants of the program. Further, client exit interview from DR center was conducted to assess the further information on adherence of contact tracing from patients and their family members perspective. Total 28 participants were interviewed from two districts. Similarly, secondary data of all DR patient from past one year were extracted using data extraction checklist. More than two third (69%) of the family member of the DR TB had participated for at least one time contact tracing throughout their treatment period until the study was conducted. Two new cases of TB were diagnosed from 47 presumptive TB cases who were in close contact with index DR TB patients As per the assumption criteria for adherence that I have kept in the study, health workers and VCT adherence to CT guideline among DR TB close contacts standard operation procedures is found to be medium. Study explores different barrier and facilitators for conducting CT among DR TB close contacts. Insufficient infrastructure, CT limited to household member only, lack of adequate training and orientation and persistent stigma were identified as major barrier for conducting CT. Likewise changing perception on TB and towards CT, incentive for health workers and VCT for conducting CT and use of local health workers to conduct CT, are major factors that are acting as facilitator to conduct CT. Contact tracing activities for DR TB close contact program is being implemented with real field based practical and resource limited setting. Study suggests expanding the boundary of conducting CT beyond family to social contact, to increase efforts on advocacy and lobbying of CT among the periphery health workers, provision of separate CT staff, expanding the DR centers and Gene Xpert centers to periphery health institution and empower the staff by providing training to increase the coverage and adherence of CT among DR TB contacts.

Kata Kunci : Tuberculosis, MDR TB Contact Tracing, Contact Tracing, TB