Bhawana Shrestha at the Tuberculosis Hospital in Kalimati says up to 12,000 TB cases may be missing from that total because patients do not have access to government diagnostic facilities. She says tools like GeneXpert should be expanded to improve surveillance.
In 2014, WHO passed a resolution to reduce TB mortality by 95% and to cut new cases by 90% by 2035. But experts say countries like Nepal with very high rates of latent infections are unlikely to meet the target. Mantoux tuberculin skin tests show that most adult Nepalis are carriers of the TB bacillus.
At Patan Hospital this week, physician Gyan Krishna Kayastha was examining x-ray reports of 50-year-old Bunu Maya Tamang who was tested positive after a sputum test, and is responding well to antibiotic treatment (above).
In Nepal, children below the age of five whose family members have positive sputum tests, and people living with HIV are provided with latent infection treatment known as Isoniazide Preventive Therapy, but Kayastha says preventive antibiotic treatment for healthy adults is impractical in Nepal because 90% of people carry the bacillus.
“Even I am probably a carrier because I am exposed to tuberculosis patients, but I would not take this test because latent TB is so common,” he adds.
Nepal also has the added challenge of an open border with India, a global hotspot for TB and its drug resistant variety. “Unless TB is controlled in India, it is unlikely the situation in Nepal will improve,” says Bhawana Shrestha. “The open border means migrant workers are bringing infections home, and a lot of patients from India come to Nepal for treatment.”
Russia, India, China, South Africa and Brazil account for nearly 60% of all drug resistant infections worldwide, while South Asia is home to 40% of the global TB burden with over 4 million cases. The region also has a disproportional share of TB deaths (40% of total fatalities worldwide), with a third of them because patients with drug resistance fail to respond to treatment. The SAARC TB Centre is located in Kathmandu and is involved in research, prevention and control of tuberculosis, TB/HIV co-infection.
Worldwide only 12.5% of TB patients have HIV, and the number comes down to 3.5% in South Asia, yet most of the research and investment is focused on HIV associated TB. Whereas worsening air pollution, smoking, malnourishment, diabetes and alcoholism are bigger risk factors for TB infection in the region.
“There is a large number of people with TB in South Asia, in particular India. This means they have a big enough sample size to conduct studies and trials for new drugs with shorter regimen,” says Buddha Bansyat of the Patan Academy of Health Sciences.
In a paper he co-authored recently in Multidisciplinary Respiratory Medicine, Basnyat concludes: ‘From bacterial biochemistry to policy implementation, South Asia can seize the opportunity to lead global TB elimination and we cannot defeat TB without understanding how to eliminate it in South Asia.”
Tuberculosis was neglected, underfunded and under-lobbied for so long because it was mainly a disease of poor people. In Nepal, DOTS (Directly Observed Treatment Short-course) was considered a success story with its supervised antibiotics administration to patients. But experts say new funding is now needed for a much more aggressive case detection system.
Nepal’s rapid development and population mobility makes it important for the government to step up the momentum to fight tuberculosis with better diagnosis and treatment. For this, it may need to replicate the Zero TB City model in the region, and go district-by-district to eradicate the bacillus in all patients and carriers.
Says Maxine Caws: “If we keep on doing what we are doing, we will still be here in 50 years time.”
The return of the microbes by Sunir Pandey
Poor Health, Editorial