Pandemic eclipses Nepal's TB epidemic

Daily wage labourers Dharma and Gita lost their jobs during the pandemic. The young couple exhausted their meagre savings in less than a month, after which they started to buy food on credit. Still unable to repay loans, they limited their diet to one small meal a day.

Soon, Gita started feeling weak. She often had a fever and cough. As the lockdown extended, her health deteriorated and the medicines were of little help. The couple even took a PCR test which came out negative. They visited five different health centers and bought bags full of medicines. The treatment was so expensive they had to sell their two cows. A month later, and heavily in debt, she was diagnosed with tuberculosis.

Tuberculosis mainly afflicts the poorest. The numbers are staggering: one in every three people globally is infected by Mycobacterium tuberculosis, and even if they carry the bacteria most people do not get sick unless their immune system is weakened due to disease or malnutrition.

And yet, this easily preventable and curable biblical disease thrives in Nepal and the Subcontinent due to inadequate measures taken to prevent, diagnose and treat the infection.

A 2020 National TB Program report revealed that over 100,000 people are living with tuberculosis in Nepal. This figure is much higher than previously estimated but has most likely increased since as many patients have been unable to access treatment during the pandemic.

Of these cases, 40,000 patients were not diagnosed or treated at government centres, which means nearly one in every two people were not diagnosed. Oftentimes, people reach standard TB treatment and care after months or even years. Their pathway to cure is complex, long and include misdiagnosis leading to unnecessary prescriptions. This in turn could lead to unnecessary death and suffering. Patients are also ostracised by friends and families, resulting in self-isolation from communities.

These challenges are exacerbated by Nepal’s limited health infrastructure. Health care centres are understaffed and poorly managed, maintenance of laboratory equipment, as well as supply of quality chemicals for tests, are erratic.

Across Nepal’s Tarai, settlements are overcrowded, people live in extreme poverty, hygiene and sanitation are at a bare minimum. In the hills and the mountains, difficult geographical terrain and poor road networks pose obstacles for people seeking health care.

These deeply-rooted structural inequities collectively resulted in magnified impact on TB service delivery during the pandemic. As a result, we observed increased deaths from the disease.

In 2018, global leaders committed to reducing TB by 2022. To meet this goal, we need comprehensive intervention programs with sufficient investment for prevention, early diagnosis and treatment. There are four key areas that require increased funding to decrease TB fatalities:

1 Prevention

We saw how the world community got together to rapidly develop vaccines for Covid-19 with unprecedented funding and resources. TB on the other hand has only one vaccine and a very weak one at that. Developed over a century ago, BCG does not prevent adults from developing TB disease.

UnderNepal's national TB program, young children living with adults who have TB are provided medicines to kill any TB bacteria they have inhaled and prevent the development of the disease. The Birat Nepal Medical Trust for the first time in Nepal is providing a shorter 12-dose course of TB preventative medicine to adults infected with the bacteria to stop them from getting sick and spreading the disease.

In 2020, only $684 million of the estimated $2.16 billion needed globally for TB research and development was available from donors. Covid-19 on the other hand received over $100 billion in just two years to develop vaccines. The pandemic exposed this global inequity, and is proof of what sufficient funding and political commitment can achieve.

If funding for the global TB prevention program is increased by 3-4 fold, we could design better community-based services, develop a more effective vaccine and promote shorter treatment regimens, all of which will achieve a TB-free Nepal sooner.

TB awareness and health promotion messages also do not get as much coverage in the media as they used to. World TB Day, observed every year on 24 March, should serve as a reminder that TB is an epidemic and needs accelerated efforts for elimination.

2 Diagnosis and Innovation

Government health centres provide TB diagnosis and treatment free of cost. Yet, people spend a lot of money and time before they are correctly diagnosed and enrolled in treatment. This is because symptoms of the disease are common to many infections. People develop cough and fever and immediately resort to taking paracetamol and general antibiotics before realising that they have TB.

Moreover, Nepal needs to quickly adopt GeneXpert machines which use PCR testing, and chest X-ray that diagnoses early-stage TB effectively and efficiently. Investment should be concentrated to expand, strengthen and maintain these diagnostic tools at health centers all over the country. Health care providers should be similarly trained to operate these machines.

GeneXpert technology should be deployed with active case finding where community health workers make home visits to screen and identify TB patients. This method also commonly known as contact tracing was applied in containing the spread of the Covid-19 virus, and has been used in TB programs for decades.

Although proven to be effective, new diagnostic technologies are expensive and active case-finding strategies require large and sustained financial commitments. One might question if a country like Nepal can afford such investments. But the question we should be asking is, can we afford not to?

The costs of the continued TB epidemic are far greater than the investments required to reduce it. Investing in better  tools including tax waivers on the import of TB diagnostic machines and test kits, and increased global funding for implementation of active case finding strategies for low and middle-income countries like Nepal are urgently needed.

3 Community-based Treatment and Care 

Incomplete or delayed treatment can cause drug resistant TB and even death. Therefore, the treatment of tuberculosis should be patient-centred.

TB programs have been implemented in Nepal for over half a century, we now have plenty of experience to employ the best strategies and  to eliminate the scourge.

One of the challenges to eradicating TB is the long duration of treatment. Under the DOTS program, tuberculosis patients have to visit health centres daily for medication to be taken in the presence of care providers. But this could expose them to other TB patients, and resulting stigma. It is also time-consuming and comes with additional transport expenses.

Investment in research and development of shorter course treatment regimens, and scaling up telemedicine is a priority area.

4 Social Protection 

TB and poverty form a vicious cycle, each fuelling the other. It is mainly the neediest in society who are most affected. Having TB increases financial strain in their families with far-reaching socio-economic consequences. Children may have to forgo education and seek employment to compensate for the loss of income in families with an infected adult. Providing cash to families after the diagnosis will alleviate the financial burden.

TB also causes malnutrition making people more vulnerable. Providing diversified food packages with appropriate nutritional value will be a big support, it will also help reduce the mental stress of fulfilling family needs.

But these are just a few recommendations, a study to identify feasible and acceptable support for people with TB will enable us to design an improved tuberculosis support program. These should incorporate health education to people with TB and their families to better understand the disease, cope with its treatment and overcome stigma.

Ultimately, it is the government’s responsibility to protect the lives of its people. Therefore, investing in and incorporating locally appropriate social protection schemes within the TB program should be the key agenda and priority of policymakers.

The slogan this World TB Day today on 24 March is ‘Invest to End TB. Save Lives’, which reiterates the need to increase funding to prevent, diagnose and treat TB. Without substantial investments that will accelerate collective efforts of the community, country and the world, it is unlikely we will win the fight against TB, reverse the huge setback caused by the pandemic or save lives.

Kritika Dixit is the Research Manager at Birat Nepal Medical Trust (BNMT) and a doctoral student at Karolinska Institutet, Sweden. Rajan Paudel is the Research Associate at BNMT.

Read also: For Nepal, a game-changer in TB control, Buddha Basnyat and Maxine Caws