Prevalence of methicillin-resistant Staphylococcus aureus in a tertiary hospital in Nepal

SETTING:

Patan Hospital, Lalitpur, Nepal.

OBJECTIVES:

To describe 1) the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and its antibiotic sensitivity pattern; 2) the demographic and clinical characteristics associated with MRSA infections; and 3) the treatment outcomes of in-patients with MRSA infection among patients with S. aureus infection between January 2018 and December 2020.

DESIGN:

This was a cross-sectional study using electronic and paper-based hospital records of patients with S. aureus infection.

RESULTS:

Of the 1,804 patients with S. aureus infection, 1,027 patients (57%, 95% CI 55–59) had MRSA. The MRSA were susceptible to vancomycin (100%), linezolid (96%), doxycycline (96%), chloramphenicol (86%) and cotrimoxazole (70%), and resistant to erythromycin (68%), clindamycin (56%), gentamycin (58%), ciprofloxacin (92%) and ofloxacin (91%). The prevalence of MRSA was higher in 2019, among out-patients, and in respiratory samples, and lower in blood samples. Of the 142 in-patients with MRSA, 93% had a successful clinical outcome (cured/improved).

CONCLUSION:

More than 50% of patients with S. aureus infection had MRSA that were resistant to commonly available antibiotics. This calls for strengthening surveil-lance and good infection control practices in this hospital.

Unfavourable outcomes among patients with MDR-TB on the standard 24-month regimen in Maharashtra, India

Setting: Patients with multidrug-resistant tuberculosis (MDR-TB) registered for treatment (2011-2012 cohort) using the standard 24-month regimen, under the Revised National TB Control Programme's programmatic management of drug-resistant TB (PMDT), Maharashtra, India. Objectives: To assess the treatment outcomes and the timing and risk factors for unfavourable treatment outcomes, with a focus on death and loss to follow-up (LTFU). Method: This was a retrospective cohort study involving a review of PMDT records. Treatment outcomes were reported on 31 December 2014. Results: Of 4024 patients, treatment success was recorded in 1168 (29%). Unfavourable outcomes occurred in 2242 (56%), of whom 857 (21%) died and 768 (19%) were lost to follow-up. Treatment outcomes were missing on record review for 375 (9%) patients, and 239 (6%) were still undergoing treatment. Half of LTFU occurred within 3 months, and more than four fifths of deaths occurred after 6 months of treatment. Human immunodeficiency virus infection, being underweight, age ⩾ 15 years, male sex and pulmonary TB were the main risk factors for death, LTFU or other unfavourable treatment outcomes. Conclusion: The study found poor treatment outcomes in patients with MDR-TB registered for treatment in Maharashtra, India. Interventions are required to address the high rates of LTFU and death.

Using mHealth to enhance TB referrals in a tribal district of India

Background: A mobile health (mHealth) technology based application was developed to help rural health care providers (RHCPs) identify and refer presumptive tuberculosis (TB) patients to the nearest microscopy centre for sputum examination using mobile applications on their smart phones. Objective: To determine the feasibility and yield of presumptive TB case referrals by RHCPs using mHealth technology. Methods: The project was implemented in the tribal population of Khunti District, Jharkhand State, India, from April 2012 to February 2015. 'ComCare', a mobile application designed as an aid for health care providers, was introduced and RHCPs were trained in its use. Results: Of 171 RHCPs who were formally trained to identify and refer presumptive TB patients, 30 were trained in the use of the mobile application. There were 35 referrals of presumptive TB patients per RHCP using the mobile application, and four each by RHCPs who were not using the application. Of the 194 TB cases diagnosed, RHCPs using the application contributed 127 (i.e., 4 TB cases per RHCP), while other RHCPs contributed 67 (0.5 TB case per RHCP). Conclusion: mHealth technology was highly effective, and increased both public and private health care provider accountability to patients.

Compliance with infection control practices in sputum microscopy centres: a study from Kerala, India

BACKGROUND

One of the strategies of the Revised National Tuberculosis Control Programme in India to achieve tuberculosis control is by increasing case detection through a nationwide network of designated microscopy centres (DMC). Practice of standard precautions for infection control in these DMCs is very important to prevent transmission of infection not only to the laboratory personnel, but also to the general population. However, in India this has not been evaluated by an external agency.

METHOD

A cross-sectional study was carried out to assess knowledge, facilities and compliance regarding infection control practices (ICP) in all 38 DMCs in Kannur district, Kerala, India, in 2015. Using observations and interviews, the investigators collected data in a structured format.

RESULTS

Overall knowledge about infection control was found to be satisfactory among 29% of laboratory technicians. Overall facilities for infection control were satisfactory in 61% of the DMCs, while adherence to ICP was satisfactory in 45% of the DMCs. Knowledge regarding ICP was better in government DMCs, whereas facilities for ICP and adherence to biomedical waste management guidelines were better in private DMCs.

CONCLUSION

Given the higher risk of infection among laboratory technicians, there is an urgent need to address the shortcomings in infection control practices.

Retention in pre-antiretroviral treatment care in a district of Karnataka, India: how well are we doing?

SETTING

Antiretroviral treatment (ART) Centre in Tumkur district of Karnataka State, India. There is no published information about pre-ART loss to follow-up from India.

OBJECTIVE

To assess the proportion lost to follow-up (defined as not visiting the ART Centre within 1 year of registration) and associated socio-demographic and immunological variables.

DESIGN

Retrospective cohort study involving a review of medical records of adult HIV-infected persons (aged ⩾15 years) registered in pre-ART care during January 2010-June 2012.

RESULTS

Of 3238 patients registered, 2519 (78%) were eligible for ART, while 719 (22%) were not. Four of the latter were transferred out; the remaining 715 individuals were enrolled in pre-ART care, of whom 290 (41%) were lost to follow-up. Factors associated with loss to follow-up on multivariate analysis included age group ⩾45 years, low educational level, not being married, World Health Organization Stage III or IV and rural residence.

CONCLUSION

About four in 10 individuals in pre-ART care were lost to follow-up within 1 year of registration. This needs urgent attention. Routine cohort analysis in the national programme should include those in pre-ART care to enable improved review, monitoring and supervision. Further qualitative research to ascertain reasons for loss to follow-up is required to design future interventions.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

Diabetes mellitus and smoking among tuberculosis patients in a tertiary care centre in Karnataka, India

Diabetes mellitus (DM) and smoking are risk factors for adverse outcomes in the treatment of tuberculosis (TB). In a tertiary care hospital at Belgaum in the South Indian State of Karnataka, all TB patients aged ≥18 years consecutively diagnosed from February to September 2012 were evaluated for DM and smoking. Of 307 TB patients, 35.5% were found to have DM, 9.8% were current smokers, and 3.6% had DM and were also smokers. Measures to assess and address both these factors need to be taken into account during TB treatment.

Epidemiology and interaction of diabetes mellitus and tuberculosis and challenges for care: a review

The global burden of diabetes mellitus (DM) is immense, with numbers expected to rise to over 550 million by 2030. Countries in Asia, such as India and China, will bear the brunt of this unfolding epidemic. Persons with DM have a significantly increased risk of developing active tuberculosis (TB) that is two to three times higher than in persons without DM. This article reviews the epidemiology and interactions of these two diseases, discusses how the World Health Organization and International Union Against Tuberculosis and Lung Disease developed and launched the Collaborative Framework for the care and control of TB and DM, and examines three important challenges for care. These relate to 1) bi-directional screening of the two diseases, 2) treatment of patients with dual disease, and 3) prevention of TB in persons with DM. For each area, the gaps in knowledge and the priority research areas are highlighted. Undiagnosed, inadequately treated and poorly controlled DM appears to be a much greater threat to TB prevention and control than previously realised, and the problem needs to be addressed. Prevention of DM through attention to unhealthy diets, sedentary lifestyles and childhood and adult obesity must be included in broad non-communicable disease prevention strategies. This collaborative framework provides a template for action, and the recommendations now need to be implemented and evaluated in the field to lay down a firm foundation for the scaling up of interventions that work and are effective in tackling this dual burden of disease.

Screening tuberculosis patients for diabetes in a tribal area in South India

SETTING

Ten peripheral health institutions of a tribal tuberculosis unit, Saluru, Vizianagaram District, South India.

OBJECTIVE

To assess among tuberculosis (TB) patients: 1) the feasibility of screening for diabetes mellitus (DM), 2) the prevalence of DM, 3) the demographic and clinical features associated with DM, and 4) the number needed to screen (NNS) to find one new case of DM.

DESIGN

Cross-sectional study: all TB patients registered from January to September 2012 were screened for DM using a screening questionnaire and random blood glucose, followed by fasting blood glucose (FBG) measurements using a glucometer. DM was diagnosed if FBG was ≥126 mg/dl.

RESULTS

Of 381 patients, 374 (98%) were assessed for DM, suggesting feasibility of screening, and 19 (5%) were found to have DM (12 were newly diagnosed and 7 had a previous diagnosis of DM). The only characteristic associated with DM was age ≥40 years. The NNS to detect a new case of DM among all TB patients was 31; among those aged ≥40 years, the NNS was 20, and among current smokers it was 21.

CONCLUSION

Screening of TB patients for DM was feasible and effective, and this should inform national scale-up. Other key considerations include the continued provision of free TB-DM screening, with co-location and integration of services.

Extending tuberculosis notification to the private sector in India: programmatic challenges?

In May 2012, the Government of India declared tuberculosis a notifiable disease, requiring all public and private health sectors throughout the country to report all cases. Until then, TB disease was notifiable only by public authorities. In India, the private sector dominates anti-tuberculosis treatment, and poorly managed cases lead to severe forms of TB. Several challenges need to be addressed for effective implementation, including the creation of an electronic case-based web-based mechanism for TB notification. Stricter enforcement backed by regulation and punitive measures for non-compliance, along with vigilant mechanisms in place to monitor private health facilities, is required. Massive campaigns and advocacy programmes for a notification drive may be the way forward.

Follow-up examinations: are multidrug-resistant tuberculosis patients in Uttar Pradesh, India, on track?

SETTING

All multidrug-resistant tuberculosis (MDR-TB) patients who had completed 6 months of treatment under the Revised National Tuberculosis Control Programme (RNTCP) in Uttar Pradesh, the largest state in northern India.

OBJECTIVE

To determine the proportion of MDR-TB patients with regular follow-up examinations, and underlying provider and patient perspectives of follow-up services.

METHODS

A retrospective cohort study was undertaken involving record reviews of 64 eligible MDR-TB patients registered during April-June 2013 in 11 districts of the state. Patients and programme personnel from the selected districts were interviewed using a semi-structured questionnaire.

RESULTS

A total of 34 (53.1%) patients underwent follow-up sputum culture at month 3, 43 (67.2%) at month 4, 36 (56.3%) at month 5 and 37 (57.8%) at month 6. Themes associated with irregular follow-up that emerged from the interviews were multiple visits, long travel distances, shortages of equipment at the facility and lack of knowledge among patients regarding the follow-up schedule.

CONCLUSION

The majority of the MDR-TB patients had irregular follow-up visits. Provider-related factors outweigh patient-related factors on the poor follow-up examinations. The programme should focus on the decentralisation of follow-up services and ensure logistics and patient-centred counselling to improve the regularisation of follow up.

Universal health coverage in a regional Nepali hospital: who is exempted from payment?

This study assessed the characteristics of beneficiaries of a government-led policy of exemption for payment being provided in a regional hospital in Nepal. In January and February 2012, 9547 patients sought services at the out-patient clinic, the majority (83%) of whom were from the same district although this was a referral hospital for 15 districts. Only 10.8% received exemption from payment; 66% of the individuals aged >60 years and eligible for exemption were missed. These shortcomings highlight intrinsic weaknesses in the current implementing mechanisms for payment exemption, which may not be providing financial protection. This hampers efforts towards achieving universal health coverage.

Did successfully treated pulmonary tuberculosis patients undergo all follow-up sputum smear examinations?

To assess response to anti-tuberculosis treatment as per national guidelines, a retrospective record review was undertaken in four districts of Andhra Pradesh, India, in December 2009 to determine whether pulmonary tuberculosis (PTB) patients reported as successfully treated (cured or treatment completed) underwent all scheduled follow-up sputum smear examinations. In a quarterly cohort of 3000 PTB patients reported as successfully treated, 1847 (61.5%) underwent all follow-up sputum examinations, with a higher proportion of new cases (65%) than retreatment cases (45%). The mid-continuation phase follow-up sputum examinations were commonly missed, and 11% patients had not undergone end-of-treatment follow-up sputum examinations.