In Nepal, a new TB challenge

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Dr. Prakash Mishra, director of the Regional TB Centre in Pokhara, Nepal, looks at a chest X-ray of a patient. Photo by Kiran Panday

KATHMANDU, Nepal – In a walk-up doctor’s office, off a busy street in Kathmandu, Dr. Dirgh Singh Bam sees patients every day in relative anonymity. His walls, though, reveal a history of being in the limelight: plaques and ribbons and framed photographs covering every inch, highlighting Dr. Bam’s efforts in leading Nepal’s TB control program from 1995 to 2004.

With assistance from the World Health Organization, Bam and a dedicated team of health workers ushered in an era of DOTS – directly observed treatment, short-course – by traveling all around the mountainous country to ensure that the strategy was followed. Health workers had to watch each patient swallow their TB pills every day.

“We made sure we had a DOTS committee in every sub-health post, every health post, every district hospital and the central hospital,’’ Bam said. “We went to mosques, temples, churches, all religious organizations, just to make sure they supported us.’’

In five years, Nepal installed the DOTS strategy across the country. In 1995, Nepal’s TB cure TB rate was around 45 percent; today it is 90 percent.

These advances made Nepal a model country around the world in TB control. But the question today is whether the country can remain a leader.

It has a major new challenge: controlling the spread of multi-drug resistant TB (MDR-TB) and extensively drug resistant TB (XDR-TB).

I traveled in Nepal for two weeks earlier this month to look at the country’s TB response from urban Kathmandu slums to remote hill stations, and what I found was a program in the midst of a major transition.

No MDR patients in isolation

Instead of putting infectious patients with drug-resistant strains in isolation, Nepal allows them to go back into the community. It doesn’t have much choice. The country has no dedicated TB hospital, nor does it have funds to create isolation wards in hospital wings. The country’s five-year National Strategy Plan, initiated in July, calls for creating 10 hostels for MDR or XDR patients.
Still, that won’t meet demand. In the last five years, the country has registered 826 MDR and 10 XDR patients.

“At this point, we just don’t have the resources to put everyone in a hospital, or hostel,’’ said Dr. Kashi Kant Jha, director of the National Tuberculosis Centre. “But I think what our record shows is that we’ve been able to get good results without hospitalization.’’

The country’s MDR cure rate is 71 percent, one of the highest figures in the developing world.

Dr. Mohammad Akhtar, a Kathmandu-based WHO Medical Officer specializing in tuberculosis, said Nepal’s MDR program has been excellent so far. “It’s one of the very few examples of fully ambulatory MDR programs at the moment in the world,’’ he said. “There were some problems early on of people defaulting, or not taking their medicines, but now more than 80 percent complete treatment.’’

Jha said his focus now is to do a more active search of people who have TB but haven’t been diagnosed. “We need to get them on treatment,’’ he said. “If we give them proper treatment, that’s the best way to stop MDR-TB.’’

Shoring up regular TB treatment

In Pokhara, which is surrounded by snow-covered peaks in the Annapurna range, Dr. Prakhash Mishra is director of the Regional TB Centre and also a TB doctor who has a full caseload of patients. He said he sees room for improvement, and that the country needs to acknowledge that some of the MDR cases resulted from poor DOTS treatment.

“We could be doing DOTS in a much better way,’’ he said. “And we should start up these hostel facilities for MDR and XDR patients as soon as possible. It’s a risk if these MDR or XDR patients are staying with their families.’’

He pointed to a waiting area outside the TB centre in Pokhara, where a half-dozen patients talked or sat by themselves until they felt well enough to travel back to their home. For MDR patients, the drug regimen frequently made them feel nauseous and too weak to walk any distance, at least for an hour or two after taking the medicine.

But the drugs also brought many back to life. “Before I was taking TB medicine, I couldn’t walk to this clinic, which is about a half-hour from my home,’’ said Rabi Pariyar, 32, a laborer. “Now I can do it easily. The drugs have made such a difference.’’

Missing home

Standing nearby, Dil Kumari Thapa, who is in her 60s, said she had taken five months of her drug regimen for MDR TB and still had more than a year to go.

“I’m feeling much better physically, but emotionally I’m often sad,’’ Thapa said. “TB has made me cry all the time. I want to go home – to my life in the village.’’

In the village, about a four hours drive from the TB centre, lives her husband, her friends Khagisara and Ramishara, her two oxen and two goats, and her radio and garden. She misses all of it.

“TB is very serious,’’ she said. “I knew nothing about it before. Now these drugs that I take they make me go a little crazy. They make me sad. But I know how important it is to take the drugs. It’s just such a long time.’’

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