TUBERCULOSIS-CONTROL IN REMOTE DISTRICTS OF NEPAL COMPARING PATIENT-RESPONSIBLE SHORT-COURSE CHEMOTHERAPY WITH LONG-COURSE TREATMENT

SETTING: A tuberculosis programme in hill and mountain districts of Ne pal supported by an international nongovernmental organisation (NGO). OBJECTIVE: To evaluate under programme conditions the effectiveness of unsupervised monthly-monitored treatment using an oral short-course r egimen. DESIGN: In this prospective cohort study, outcomes for new cas es of smear-positive tuberculosis starting treatment over a two-year p eriod in four districts in which a 6-month rifampicin-containing regim en was introduced as first-line treatment (subjects) were compared to outcomes for similarly defined cases in four districts where a 12-mont h regimen with daily streptomycin injections in the intensive phase co ntinued to be used (controls), RESULTS: Of 359 subjects started on the 6-month regimen, 85.2% completed an initial course of treatment compa red to 62.8% of 304 controls started on the 12-month regimen (P < 0.00 1); 78.8% of subjects and 51.0% of controls were confirmed smear-negat ive 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 smearnegative without retreatment, compared to 60.9% of controls (P < 0.001). CONCLUSION: In an NGO-supported tuberculosis control prog ramme in remote districts of Nepal, patient-responsible short-course t herapy supported by rapid tracing of defaulters achieved acceptable ou tcomes. Where access and health care infrastructure are poor, district -level tuberculosis teams responsible for treatment planning, drug del ivery and programme monitoring can be an appropriate service model.