Tuberculosis is curable and preventable. But this neglected infectious disease, which spreads from person to person through the air, still kills around 46 people a day in Nepal, or around 17,000 people a year.

“The number is huge,” says Dr Sanjaya Kumar Thakur, director at the National Tuberculosis Control Centre. “But still there is not much conversation about this disease.”

Tuberculosis, or TB in short, is caused by Mycobacterium tuberculosis that most often affects the lungs. When people with TB cough, sneeze or spit, they emit the TB germs into the air, and a person who inhales even a few of these germs can get infected. That’s why it becomes difficult to check the spread of TB, experts say.

According to the World Health Organisation’s Global Tuberculosis Report 2021, every year 10 million people fall ill with tuberculosis. The UN health agency says around 1.5 million people die globally every year due to TB, making it the world’s top infectious killer.

The National Prevalence Survey 2018-19 estimated that 117,000 people are currently living with TB in Nepal.

According to data provided by the Ministry of Health and Population, only 28,677 people tested positive for tuberculosis in the fiscal year 2020-2021 out of an estimated 69,000 new cases. It is only around 40 percent of the total estimated new cases.

“The major challenge is tracing the whereabouts of TB patients,” says Mukti Khanal, the chief at Planning, Monitoring, Evaluation and Research Section at the National Tuberculosis Control Centre. “When infected people do not get diagnosed, the bacteria continues to spread through them. This complicates the problem.”

Nepal has committed to ending TB through the WHO END TB Strategy by 2035. But the National Prevalence Survey carried out in 2018-019 with the technical and financial support from the UN health body showed that the country is “not on track’ to meet the target.

Officials concede that Nepal will not be able to meet the target even in the next 125 years if intervention strategies are not changed.

Nepal started providing TB treatment some 85 years ago, but it continues to remain one of the major public health burdens.

The study showed around 190 people get infected every day although the government’s earlier estimates had put the number at 123. Similarly, the government’s estimates made before the study had put the daily TB deaths at 18-22.

The Covid-19 pandemic in the last two years also came as an obstacle to Nepal’s TB treatment efforts.

Detection of new tuberculosis cases has declined by 50 percent ever since the government enforced a nationwide lockdown on March 24, 2020, according to an assessment carried out in all seven provinces and the Kathmandu Valley by the National Tuberculosis Control Centre.

The drop in TB cases has been attributed to the closure of transportation services, which restricted patients’ access to health facilities. During the lockdown period, infected people were even deprived of regular medication, which is estimated to have fuelled multidrug resistance tuberculosis cases.

When TB patients discontinue their medicines, they develop a resistance to the drugs, which results in multidrug resistance tuberculosis, or MDR-TB. Such people with MDR-TB then continue to spread the disease to others. The treatment success rate of drug sensitive tuberculosis is around 91 percent whereas the same for multi-drug resistant TB is only around 72 percent in Nepal.

Experts say even after the end of the lockdown and lifting of all restrictions following the decline in new Covid-19 cases from the first, second and third waves, new TB cases have not been diagnosed significantly, which, according to experts, is a cause for concern.

The number of estimated multi-drug resistant tuberculosis patients is 2,200 every year, which is very high as per the population size of the country. But only 569 people were detected in the last fiscal year. Of them 418 enrolled for treatment. Prevalence of multidrug resistant tuberculosis has risen more than 15 percent, which was less than two percent in the past, according to the Health Ministry.

A combination of antibacterial medications are provided for a period of six to twelve months for the treatment of TB. The government provides free treatment to TB patients through 5,503 DOTS (directly observed treatment, short-course) centers. These centers are operated from state-run health facilities, community health facilities and some privately owned health centres.

The World Health Organisation has put Nepal on the list of 30 countries having high prevalence of multidrug-resistance tuberculosis.

Public health experts say despite the fact that TB is a major killer in Nepal, not much attention has been paid to prevent the loss of lives from the infectious disease.

“Only around less than one fifth of the people infected with multidrug resistant tuberculosis are getting treatment,” said Dr Kedar Narsing KC, a tuberculosis expert and chest physician. “Around 1,800 people are deprived of treatment every year. This is not as light an issue as it is considered.”

According to the WHO, people infected with TB bacteria have a lifetime risk of 10 percent of falling ill with TB. However persons with compromised immunity such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a much higher risk of falling ill.

People ill with TB can infect up to 10-15 other people through close contact over the course of a year, says the UN health agency. Without proper treatment, up to two thirds of people ill with TB will die.

Experts say several reasons including a lack of commitment has worsened TB situation in the country.

“No rocket science is needed to control the TB problem in our country,” Dr Dirgha Singh Bam, a TB expert, who is also a former Health Secretary, said. “What is needed is a commitment to end TB from all sectors including from political leadership and follow the strategies we made earlier.”

Bam said that authorities should increase the investment in tuberculosis, ensure free treatment, which is also in line with the WHO’s end TB strategy.