3 Sep 2017

The annual review of the National Tuberculosis Programme (NTP) took place from 3-13 September 2017 to review the performance of Nepal NTP.

Strengths in the fight against tuberculosis (TB) in Nepal are noted:

  1. The National Strategic Plan (NSP) for TB Prevention, Care and Control 2016/17-2020/21 has been endorsed by Ministry of Health.
  2. The Government of Nepal have used domestic funding to cover 100% first line anti-TB drugs and an increased proportion (40% – 60%) of second line anti-TB drugs.
  3. National TB Centre (NTC) has new leadership and is fully committed in the fight against TB in Nepal.
  4.  Pre-testing of TB prevalence survey has been successfully conducted.
  5. The number of Xpert sites has increased.
  6. NTP has planned to introduce shortened MDR-TB regimen.
  7. NTP Clinical Manual 2017, National Childhood TB Management Guideline 2017 and Community System Strengthening Strategy have been finalized.
  8. Programmatic management of drug-resistant TB (PMDT) Guideline and Public Private Mix (PPM) Strategy and Guidelines for TB control are under preparation.
  9. Testing of HIV among TB patients has increased.
  10. There was no reported stock out of anti-TB drugs.
  11. External quality assurance of smear microscopy is in place.

Several constraints were identified:

  1. Under a federal structure, Nepal has been divided into 7 provinces, 77 Districts and 753 local government units, but the new structure of NTP has not been clarified.
  2. Case finding of TB continue to decrease in the year 2015/16, especially clinical diagnosed pulmonary TB cases.
  3. The majority of smear microscopic centres had a relatively low number of presumptive TB examined for diagnosis due to 1) unclear criteria of establishing a microscopic centre, and 2) lack of sensitization of health care workers in effective identification of presumptive TB cases.
  4. An effective sputum currier system has yet been established, and the number of specimens sent was relatively small.
  5. Clinical diagnosed pulmonary TB cases were diagnosed by medical officers (MBBS), but junior medical officers have frequent turnover and were not well trained and supervised.
  6. Revised algorithm of Xpert tests for case finding of TB and drug-resistant TB has not been finalized.
  7. The number of Xpert tests performed by most Xpert machines was relatively small, because
    1. catchment areas of Xpert sites are not clearly define,
    2. a mechanism ensuring testing of high risk groups of drug-resistant TB was lacking, and
    3. some Xpert machines were not properly maintained.
  8. Treatment outcome of MDR-TB is not satisfactory. Patient support is insufficient. Management of pre-XDR and XDR-TB cases has not been consistent. Supervision of PMDT was week, without participation of medical officers.
  9. Some drugs for shortened MDR-TB regimen and new anti-TB drugs are not yet available in Nepal.
  10. Technical supervision from central level to region and district levels is weak.
  11. Programme data were not analyzed in a critical manner and utilized for addressing programme constraints.
  12. TB Act has been endorsed by Ministry of Health but not by the Parliament, and engagement of private sector remains insufficient.
  13. Childhood TB was underdiagnosed and contact examination remains weak

Key recommendations:

  1. Under a federal structure, national NTC and seven provincial NTC will serve the managerial function of NTP; District will need to supervise activities at local units.
  2. Case finding of TB highly depends on an effective diagnostic network:
    1. Microscopic centres should be decentralized to increase accessibility but also sufficiently centralized to maintain proficiency. NTC should define the number of presumptive cases examined and the number of smear positive case detected per year as criteria for maintaining a microscopic centre, taking geographic characteristics and population distribution into account.
    2. Health care workers should be sensitized for effective identification of presumptive TB cases, and regular meetings should be organized by RTLOs/DTLOs.
    3. Sputum currier system should be established at facilities with limited access to microscopic centres. Spot sputum of presumptive TB cases who presented themselves on the day before and the day of sputum transportation should be collected. Health care workers should be trained and supervised on a regular basis.
    4. Active case finding should be conducted on a regularly basis in areas where undiagnosed prevalent TB cases is high and access to care is limited.
    5. Patients should be educated about quality sputum collection.
    6. All microscopic centres should participate in EQA; lab supervisors should conduct on-site supervision for laboratories with false positive and/or false negative errors.
  3. Management of presumptive cases with negative smear should be monitored:
    1. Use of a fluoroquinolone should be strongly discouraged through orientation.
    2. A referral system between microscopic centres without and that with medical officers is needed
    3. Medical officers should be trained for the diagnosis of clinically diagnosed TB, and their performance be monitored.
    4. Algorithm of Xpert tests among presumptive cases with negative smear should be finalized and operationalized. If CXR is required before Xpert test, accessibility and affordability of CXR should be ensured.
  4. DOTS centres should ensure risk groups of drug-resistant TB have Xpert tests. Data of such test should be collected and reviewed in trimester review meetings, followed by supervision at DOTS centres for effective action. Xpert tests among new TB patients should be performed if there are sufficient number of cartridges. Xpert machines should be properly maintained.
  5. Management of MDR-TB should be strengthened: 1) medical officers should be trained and mobilized, especially for the detection and management of adverse drug reactions, 2) supervision from NTC should include medical officers, 3) capacity of RTLOs/DTLOs on PMDT should be enhanced. 4) DR-TB treatment centres should support sub centres in patients management and drug supply, 5) turnaround time (from sputum collection till obtaining results) of Line Probe Assay should be reduced and monitored, 6) management of patients with resistance to fluoroquinolone and second line injectables should be standardized (modify regimen and continue treatment or re-start from day 0; continue treatment or declare failure at modification of regimen, etc), 7) patient support package should be enhanced to avoid catastrophic cost faced by patients and their family.
  6. Preparation for the introduction of a shortened MDR-TB regimen should be done efficiently: 1) guideline and training manual be finalized and training conducted, 2) un-interrupted supply of drugs be ensured, 3) bedaquiline obtained for the management of difficult MDR-TB patients, 4) adverse drugs reaction monitored and aDSM established.
  7. Technical supervision from central level to regions/districts should be strengthened by engaging partners, and focus on priority issues, such as case finding and PMDT.
  8. Programme data should be analyzed to identify constraints for remedial actions and published in annual TB report.
  9. NTC should advocate for TB Act to be quickly endorsed by the Parliament and to engage private sector, especially in mandatory reporting of TB. Professional Societies (such as Nepal Medical Association) should be engaged and mobilized in national adaptation and implementation of the International Standard of TB Care.
  10. The capacity of medical officers in the diagnosis of childhood TB needs to be strengthened through training and regular meetings. Contact examinations should be consistently conducted and data analyzed.