Tackling TB amidst a pandemic

Sabina Magar lost her job at a brick kiln during the Covid-19 lockdown. The 28-year-old, a single mother raising two young children, was faced with uncertainty. 

To make matters worse, she had a fever, began to lose weight rapidly and found herself constantly bed-ridden, without an appetite. When she started to cough up blood, she dragged herself to a hospital in her village in Piuthan. She was diagnosed with tuberculosis.

Tuberculosis (TB) is a common ailment in Nepal. This perfectly curable medieval disease, still kills at least 6,000 Nepalis a year. TB is in fact the biggest infectious disease worldwide, with 10 million new cases and causing 1.5 million deaths annually.

TB has been traditionally difficult to diagnose. Despite free screening and medications, poor people in rural parts cannot afford to visit health centres and hospitals in district headquarters, leading to gross underestimation of TB cases in Nepal.

A 2018 survey by the National Tuberculosis Control Center revealed that close to 70,000 Nepalis contract the infection every year, much higher than previously estimated.

The Covid-19 pandemic has further exacerbated the situation. Nationwide lockdowns and restricted mobility meant that in lack of screening, many people went undiagnosed and patients like Magar had harder time accessing free medications.

Delayed diagnosis and subsequent treatment of TB translates into enduring health impact from permanently damaged lungs. This in turn increases their risk of contracting the coronavirus.

On the flipside, safety measures taken to contain the spread of Covid-19 such as wearing masks and handwashing can significantly reduce tuberculosis infection as every other Nepali is a carrier.

TB, Sonia Awale

Magar could not take nutritious food to regain her health because of the lack of income, making her recovery difficult.

On the other hand, the standard Observed Treatment, Short-course (DOTS) requires medical supervision of the administration of antibiotic treatment to patients. This is fraught with challenges because it means travelling long distance to the health centres during which patients can continue to spread the disease. 

People are also worried about being stigmatised as TB patients and hence visit distant hospitals, walking for hours along the abandoned forest trails.

TB and Covid-19 also have a synergistic impact on economic conditions, mental health and social life. While the coronavirus is a new disease and spread rapidly by a virus, TB is one of the oldest diseases known to mankind and a ‘slow’ pandemic caused by a bacillus.

TB and Covid-19 disproportionately affect women, children, elderly and people living below the poverty line.

At the same time, the response to the pandemic has overloaded Nepal's under-resourced health system. It has set back years of hard-earned gains against other infections. So how do we guarantee free and easy access to TB services during a time of crisis?

The national TB program aims to diagnose all people with TB and leave no one behind. The right to free TB treatment should not be compromised at any cost, as the early diagnosis and treatment of every TB case, protects us all.

Understanding the multitude of ways in which the pandemic has affected TB diagnosis and treatment in Nepal is essential to repair the damage, bring services within the reach of all the citizens and rebuild a resilient health service for the future.

The lessons that we are learning from the Covid-19 response, including monitoring and the surveillance system, is an important opportunity for TB programs to develop innovative technologies for socio-culturally appropriate and people-centric care.

Nepal might be a role model in the community-based DOTS, but a more active case detection method is now required. Employing GeneXpert, a more accurate diagnostic tool and introducing drones as a form of TB telemedicine might be a start.

TB, is often called a medical poverty trap or disease of poverty and is a life-threatening disease for people living below the poverty line like Sabina. Due to the difficulties in completing the minimum six months of daily drugs, people also have a higher risk of incomplete treatment that allows the disease to take severe forms.

Sabina, fought with the disease for her two children and trusted the benefits of taking medicines which helped to regain her damaged health. Her case is a reminder to us that health needs of people is a priority of the community.

The slogan of this year’s World TB Day on 24 March ‘The clock is ticking’ prompts us to act in solidarity to take for TB prevention, diagnosis and treatment. Each one of us is responsible to achieve a TB-free future for our children.

TB patients in limbo due to COVID-19, Devika Agarwal

Kritika Dixit is a researcher with Britain Nepal Medical Trust (BNMT) and a doctoral student at Karolinska Institutet, Sweden.