TB

The high prevalence of tuberculosis in Nepal means new tools are needed to eradicate the scourge
Sonia Awale
October 5, 2018
Photo: Sonia Awale

Access has always been the biggest obstacle in diagnosing and treating tuberculosis patients in Nepal’s harsh terrain. Without reaching the poorest in the remotest villages, the country cannot meet the target of eradicating this infectious disease by 2035.

So, to find and treat patients in remote areas, health experts will soon be testing drones to fly diagnostic samples and drop off medicines in Piuthan district in Nepal’s rugged mid-western mountains. 

“Medical drones are ideally suited for remote Nepal where people with TB have to walk for hours every day to reach health posts for medication, and eventually we plan to scale it to other parts of the country,” says Maxine Caws of the Britain Nepal Medical Trust (BNMT) which is working with the Nick Simons Institute on the pilot project. (See interview, below)

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The Trust is also helping to mobilise rural female health volunteersin active case finding across Nepal. It is deploying the new GeneXpert molecular diagnostic tool that is much more accurate in detecting TB infections than the traditional sputum swab, and can also identify patients with multi-drug resistant (MDR) TB.

Tuberculosis is the biggest infectious disease worldwide, with 10 million new cases every year that kills some 1.5 million people, mainly in poor countries. Despite antibiotics, it is difficult to reach patients in underserved parts of the world, and an increasing number of patients are now developing resistance to commonly used drugs.  If nothing is done, TB could kill 50 million people by 2050. 

Prompted by this alarming prognosis, the UN General Assembly last month held its first-ever high-level meeting on tuberculosis to draw attention and generate investment for TB research, treatment and diagnosis. 

Here in Nepal, there were 45,000 reported TB cases last year. The last survey showed that among previously treated cases, anti-microbial resistance was found in 15.8% of the cases, against the world average of 18%. 

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.”

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#ENDTB

Tuberculosis expert Maxine Caws of the Britain Nepal Medical Trust spoke to Nepali Times this week about meeting the End TB target by 2035. Excerpts:

Nepali Times: How important was the UN high-level meeting on tuberculosis? 

Maxine Caws: There have been five high-level UN meetings, and this was the first ever for tuberculosis. The ones on HIV and Ebola galvanised the momentum, investment and action for those diseases. So the hope for TB is that the same thing will happen and get governments and organisations to invest in research and development.

Why is TB so underfunded?

TB affects the poorest in the society and is a long-term problem. Everybody likes short-term results, especially politicians. TB needs a long-term commitment.

Isn’t Nepal a success story for its DOTS program? 

We have been satisfied with far too little. There are still 44,000 cases and 7,000 deaths a year from a preventable, curable disease. We need to do much more and it is the right time to push for TB eradication.

Aren’t we all potential TB carriers? 

TB is hard to eradicate because of this very reason. Globally 25% of people have latent TB infection, in Nepal at least two thirds of the total population are carriers. It is higher in low-income groups.

How does HIV co-infection work?

People with HIV are much more susceptible to TB. Because of their weakened immune system, they either develop the infection or the bacilli present in their lungs activate to develop clinical TB. This is also the case for the malnourished and elderly. Most healthy individuals can control the bacillus, which is why many Nepalis are not sick despite high latent infection.

How about air pollution?

Anything that damages lungs like smoking, working in brick kilns and construction, air pollution — all increases the risk of developing TB. Children with chronic lung condition are more susceptible.

How serious is drug resistance? 

On a global scale, Nepal has been good at controlling drug resistant tuberculosis, with only 2.2% of new cases being MDR. This means there in an opportunity to stop it while it is still containable. But only a third of total MDR cases are being identified. If we do not improve diagnosis, the problem will escalate. Good news is we have two new drugs for TB but unfortunately they are not reaching the patients who need them the most.

Are we at a stage where the focus should be on treatment and cure, instead of prevention?

That is not necessarily true. Prevention, diagnosis and treatment should go together. We know we are missing TB cases, so one of the things the Britain Nepal Medical Trust is working on is active case-finding. Traditionally the health system waits for patients to come for diagnosis. In active case detection, female health volunteers gather information about household and social contacts of an infected person, talk to them and decide whether they need a test.

We are also scaling up the GeneXpert test, a molecular diagnostic tool, which has been found to be more effective than traditional smear microscopy that misses half the cases. There are 50 GeneXpert kits in Nepal, we need to expand the network.

We hear you are testing drones? 

Drones are ideally suited for the geography of remote Nepal where distance poses a challenge to accessibility of health services. We are in the process of obtaining permit for drones to transport test samples to health posts in Piuthan and fly back medicines if a patient has been tested positive. Drones will also allow the whole district to get access to GeneXpert tests, which is currently available only at the district hospital.

Can we replicate the Zero TB City initiative in Kathmandu?

Cities in the South Asia like Chennai and Karachi are moving towards Zero TB, which means finding and treating every TB case using preventive therapy systematically. We should start from smaller population and expand it to bigger cities in Nepal.

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