Nepal TB cases grossly underestimated

Paul Nunn and Bhim Singh Thakuri

Tuberculosis remains a major public health problem in Nepal, with over 32,000 notified cases and an estimated 7,000 deaths per year.

Nepal participated at the United Nations High Level Meeting on TB in September 2018 and, with all the other nations of the world, committed to end TB as a public health problem by 2035.

In June, a team of international TB experts reviewed the country’s progress against the disease, visiting five provinces. Their findings: Nepal is not on track to meet the 2035 commitment.  What is more, cases of TB in the country are much higher than we previously estimated.

There had been concern that notified cases were just the tip of the iceberg, as there was evidence that many TB cases were being missed.  The Ministry of Health and Population (MOHP) supported by the Global Fund against AIDS, TB and Malaria and the World Health Organisation, conducted a survey to measure for the first time the amount of TB in Nepal.

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Despite the terrain, this was one of the most thorough surveys ever done. Final results will be published at the end of the year, but preliminary findings show there is about two-thirds more TB than was previously estimated.

How could this be? For over 20 years, Nepal has had a National TB Programme (NTP), which provided nationwide coverage of basic services for drug sensitive TB and, more recently, for drug resistant TB. Treatment results compare favourably with other countries.

The NTP has successfully introduced modern rapid diagnostic technology (GeneXpert) and electronic reporting of cases, started a collaboration with the private sector to ensure proper management of patients, and begun a program to find and treat children with TB.

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But long-standing weaknesses in management and organisation, compounded now by the federalisation process, have allowed some of the essential functions of the NTP to disintegrate, and others are at serious risk. The laboratory network for diagnosing TB and the system of supportive supervision that ensures standards are maintained through all levels of government should be restored immediately.

This is because district centres, key to TB control strategies, were abolished — and then reinstated — but with far fewer staff than previously.

Accurate surveillance of the cases notified and the flow of information to the centre is endangered. Federalisation has so far not created clear mechanisms that will ensure these essential functions continue. If decentralised procurement of drugs continues, it will increase procurement costs significantly and risk the purchase of poor quality drugs.

Successive governments have allowed the technical staff of the National TB Centre to be hollowed out, eroding its capacity to develop policies and lead their implementation. The National Strategic Plan, written three years ago, is underfunded and only partially implemented. Most staff responsible for TB activities are now not trained to carry out the work.

Diagnosis is mostly by outdated and insensitive sputum microscopy.  Transport of specimens to laboratories is still inadequate. Consequently, GeneXpert utilisation has been slow to increase.

The private health sector is massive and growing. Over 70% of people with TB first go to private clinics, yet diagnosis and treatment are of variable quality, leading to drug resistance.

The joint monitoring mission recommended the following:

Stop the collapse of the NTP by engaging the MOHP in discussions on federalisation to ensure that the essential functions of TB control are preserved, with clear roles and responsibilities for the newly appointed staff.

Increase investment to provide technical support to all levels of the NTP through teams of staff at central and provincial levels. Let a partner employ these staff if the government cannot do so immediately.

Use these teams to address the massive training gap that hypermobility of staff and federalisation have created.

Phase out sputum microscopy for diagnosis and move to GeneXpert testing, and make sure contracted organisations achieve case-finding targets. If they do not, stop the activities and redirect the resources to more effective areas.

Fully engage with the private sector to ensure patients there are diagnosed and treated according to national guidelines.

Similarly engage with community-based organisations to help find cases and ensure they finish treatment.

Nepal must act on all these recommendations without delay to get back on track to meet its commitments.

Paul Nunn was Team Leader of the international mission and Bhim Singh Tinkari is a recent Director of the National Tuberculosis Centre

Communities against a communicable disease

TB testing by and for communities can free Nepal from its biggest infectious killer

Olivia Biermann

Ram, 65, from Makwanpur was nothing but skin and bones. He had lost his appetite and was coughing. His back pain made it difficult for him to walk and care for his chickens and buffalos, which were his main source of income. Ram was very sick, but his disease remained undiagnosed.

Over the course of a year, he had visited several private and public health facilities, and spent over Rs69,000 for different treatments. Nothing helped. Ram had given up hope of being healthy.

A partner organisation of the national TB program was targeting high-risk areas like Makwanpur for the disease by setting up neighbourhood camps to test people. Ram met volunteer Sangita, who collected his sputum sample and tested it. Ram had TB. He started treatment immediately. Six months later, the treatment completed, he was cured.

There are about 10,000 Nepalis like Ram, sick with TB but never diagnosed and treated. They continue to unknowingly transmit the disease to their families, friends and colleagues — fuelling the epidemic. Poverty increases the likelihood that a person will get sick with TB. In turn, TB can make people and their families a lot poorer.

Worldwide, TB is the number one infectious killer. The World Health Organization (WHO) estimates 3.7 million people have TB, but do not even know it.

One strategy to find these ‘missing’ TB patients is community-based screening (active case-finding). Setting up a camp, as in Ram’s neighbourhood, is only one of many examples of how this type of outreach screening can be done. It could also mean testing friends and family members of a TB patient or offering screening to high-risk groups, such as persons with HIV or diabetes, or people living in a homeless shelter.

Active case-finding is not a silver bullet to end TB. There are no silver bullets, in fact. Consequently, in countries with many TB patients like Nepal, community-based TB screening is a necessary but potentially double-edged sword in the global TB emergency.

Community screening can waste resources or increase stigma, but it can also decrease suffering and transmission – it all depends on how it has been tailored and put into practice. That is to say that this ‘sword’ should be used carefully, and by those who know when, where and how to mobilise the community.

Tailoring outreach screening approaches means considering a) global and local data and evidence, which are limited but steadily growing, and b) using the most accurate diagnostic tools, such as the molecular GeneXpert test not widely available in Nepal yet. (See article above)

Active case-finding is a balancing act. Tailoring and integrating outreach screening approaches implies that we must consider and strike a balance between:

Focusing on transmission versus individual health outcomes

Public health versus risk of harm for individuals

Employing the necessary human resources versus relying on volunteers

Achieving long-term success versus containing costs in the short-term

Proactive prevention versus reactive medical interventions.

What Nepal needs to meet its 2030 TB target, contained in the Sustainable Development Goals, is a person-centred public health and sustainability mindset. This is not an oxymoron. We need to keep the big picture in mind so that the 10,000 missing Nepali TB patients like Ram can be identified and treated. Only then can we work towards ending the TB epidemic.

Olivia Biermann of the Karolinska Institutet in Stockholm used to work for the WHO and is researching health systems and policy in low- and middle-income countries.  

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