Tuberculosis in Nepal: Burden, Free DOTS Treatment & Drug-Resistant TB

Tuberculosis, known in Nepali as kshaya rog (क्षयरोग), is a bacterial infection caused by Mycobacterium tuberculosis that most often attacks the lungs but can affect almost any organ. It spreads through the air when a person with active pulmonary TB coughs, sneezes or speaks. Despite decades of control efforts, TB remains one of Nepal's heaviest communicable-disease burdens, and Nepal is counted among the World Health Organization's (WHO) list of high-burden countries for the region.

For years Nepal's official case numbers relied on modelled estimates, but the country's first-ever National TB Prevalence Survey (conducted in 2018-19) reset the picture. It found a TB prevalence of about 416 per 100,000 population - roughly 117,000 people living with active TB at the time, which was around 1.8 times higher than previously assumed. The survey also estimated an annual incidence of about 245 per 100,000, or roughly 69,000 new cases a year, about 1.6 times the earlier estimate.

More recent WHO estimates put Nepal at around 67,000 new TB cases in 2024, of which health authorities identified about 39,151 patients - meaning a large share of cases each year are still 'missing' (never diagnosed or never notified to the program). A major reason is that many people first seek care in the private sector, whose cases historically were not fully reported. TB also kills thousands of Nepalis every year, and drug-resistant TB adds a smaller but far costlier layer to the burden.

The burden is not spread evenly. Surveys and notification data show TB is more common among the elderly and among men, and higher in the Terai and hill districts than in the mountains or inside the Kathmandu Valley. Reported notifications are also concentrated in the more populous provinces such as Madhesh, Bagmati and Lumbini.

Nepal's response to TB is coordinated by the National Tuberculosis Control Center (NTCC), the focal point of the National Tuberculosis Program (NTP) under the Ministry of Health and Population (MoHP) and the Department of Health Services (DoHS). The center is based in Thimi, Bhaktapur, and traces its roots to a national TB centre established in 1989 with Japanese cooperation, building on TB-control activity that had been organised in Nepal since the mid-1960s. The NTCC sets policy, guidelines and standards, oversees drug supply and laboratories, and monitors program performance nationwide.

The cornerstone of treatment is DOTS - Directly Observed Treatment, Short-course - the WHO-recommended strategy that Nepal rolled out nationwide from around April 2001. Under DOTS, a trained health worker or trained community volunteer watches the patient swallow each dose (or supervises via modern equivalents), which improves adherence, prevents relapse and reduces the chance of resistance developing. DOTS services are delivered through thousands of treatment and sub-treatment centres attached to health posts, primary health-care centres, hospitals and urban health clinics across the country.

Standard treatment for drug-sensitive TB follows the WHO first-line regimen of four medicines - isoniazid, rifampicin, pyrazinamide and ethambutol - typically given as two months of all four drugs followed by four months of isoniazid and rifampicin, for a total of about six months. Taken correctly, this regimen cures the great majority of patients; Nepal reports a treatment-success rate of around 90-92% for drug-sensitive TB. Stopping treatment early is dangerous because it can leave surviving bacteria that become drug-resistant.

In Nepal, TB diagnosis and treatment through the national program are provided free of charge at government health facilities. Anyone with a persistent cough or other warning signs can go to a nearby health post, primary health-care centre, district or provincial hospital, or a designated DOTS/TB centre and ask to be checked for TB. Because the medicines and standard tests are supplied by the government (with support from partners such as the Global Fund), patients should not have to pay for first-line TB drugs.

Diagnosis has shifted from older sputum-smear microscopy toward rapid molecular tests. GeneXpert MTB/RIF machines, rolled out in Nepal from around 2011, can confirm TB and detect rifampicin resistance within hours from a single sputum sample, and are provided free in government facilities that have them. Chest X-ray is often used to screen, and sputum tests confirm the diagnosis. For suspected drug-resistant or extrapulmonary TB, samples may be referred to reference laboratories for culture and further testing.

If a private clinic diagnoses TB, patients can still be linked to the free national program for their medicines and follow-up, and the NTP has worked to bring private providers into the notification and treatment system so that more cases are counted and supported. People who are unsure where to go can ask at any government health facility or contact the National Tuberculosis Control Center for referral to the nearest DOTS centre.

Multidrug-resistant TB (MDR-TB) is TB that no longer responds to the two most powerful first-line drugs, isoniazid and rifampicin; rifampicin-resistant TB (RR-TB) is treated similarly. Resistant strains usually arise when treatment is interrupted, incomplete or improperly managed, but they can also be transmitted directly from person to person. Drug-resistant TB is much harder, longer and more expensive to treat than ordinary TB, which is why completing the full DOTS course matters so much.

Drug-resistant TB is a smaller part of Nepal's total burden but a serious one. Reporting around recent years indicates only a few hundred drug-resistant cases are enrolled on treatment annually, against an estimated pool of a couple of thousand - meaning many resistant cases are still not being reached. Treatment-success rates for drug-resistant TB (reported around three-quarters of cases) are lower than for drug-sensitive TB, reflecting how difficult these cases are.

Nepal treats drug-resistant TB through Programmatic Management of Drug-Resistant TB (PMDT), using standardised regimens at designated treatment centres, with laboratory support for diagnosis. The wider availability of GeneXpert and other molecular tests helps detect rifampicin resistance earlier so that patients can be moved onto appropriate regimens sooner. Patients with drug-resistant TB need close follow-up, and stopping their treatment early is especially dangerous.

The most common form of TB is pulmonary (lung) TB, and its hallmark warning sign is a cough that lasts two weeks or longer. Because early TB can look like an ordinary chest infection, anyone with a persistent cough should be tested. TB can also affect lymph nodes, bones and joints, the abdomen, the brain (TB meningitis) and other organs, in which case symptoms depend on the site involved.

Prevention rests on a few pillars. The BCG (Bacillus Calmette-Guerin) vaccine, given to infants under Nepal's national immunisation program, protects young children against the most severe forms of TB such as TB meningitis, though its protection against adult lung TB is limited. Finding and treating cases early - so infectious patients quickly become non-infectious - is one of the strongest ways to cut transmission. Good ventilation, covering coughs, and completing the full course of medicine all reduce spread.

TB preventive treatment (a course of medicine for people with latent TB infection, such as young household contacts of a patient and people living with HIV) is another important tool used within the program. If you live with, or have spent long periods close to, someone diagnosed with TB, tell the health facility so contacts can be screened. Good nutrition and management of conditions such as HIV and diabetes, which raise TB risk, also help.

Nepal has aligned its planning with the WHO End TB Strategy, launched in 2014, which aims to reduce TB deaths by 95% and TB incidence by 90% between 2015 and 2035, with milestones along the way (for example, a 50% reduction in incidence and a 75% reduction in deaths by 2025). The strategy also calls for no TB-affected household to face catastrophic costs. These global targets sit behind Nepal's own national plans.

Through its National Strategic Plan to End Tuberculosis (covering 2021/22-2025/26), Nepal set steep goals: cutting the incidence rate from about 238 per 100,000 in 2020/21 toward roughly 81 per 100,000 by 2025/26, and reducing the mortality rate substantially over the same period. The country's stated ambitions include ending TB as a major public-health problem by 2035 and driving toward TB elimination by 2050, alongside a 'Tuberculosis Free Nepal' declaration initiative encouraging local governments to intensify case-finding.

Progress, however, has been uneven. The large number of 'missing' cases each year, the gap in reaching drug-resistant patients, and periodic disruptions (including the effects of the COVID-19 pandemic) mean Nepal is widely acknowledged to be behind the pace needed to hit the End TB milestones. Officials have emphasised that infection rates remain stubbornly high and that active case-finding, private-sector engagement and sustained funding are essential to close the gap.