National Tuberculosis Programme Nepal

National Tuberculosis Programme Nepal Post-Disaster Rapid Assessment of the National Tuberculosis Program: Preliminary Report 26th May, 2015 Government of Nepal Ministry of Health & Population Department of Health Services National Tuberculosis Centre Thimi, Bhaktapur

1. Introduction Nepal was hit by a massive earthquake on 25 April (11:56 local time) of a magnitude of 7.9 on the Richter Scale, the epicenter in Barpak VDC in Gorkha district, 80 km northwest of Kathmandu. Continued aftershocks followed throughout Nepal with one reaching a magnitude of 6.7 on the Richter Scale the following day. Two weeks later, on 12 May (12:50 local time), a big aftershock measuring 7.4 Richter Scale struck, 176 km North East of Kathmandu in Dolakha District, creating further damaged to both new and previously affected areas. The aftershocks continue to be a daily occurrence and multiple in number. For a real-time updates and a pictorial representation of the seismic activity in Nepal please refer to the below link: https://www.google.com/fusiontables/datasource?docid=1rs_s8_cd7xvbhplvm2fkw15h_r9h NZIT9MTC8UPt#map:id=3 The last time Nepal experience devastation of this magnitude was in 1934 and despite the country s preparedness plan, this disaster has left a huge challenge for us to rebuild our national heritage, our livelihoods and our healthcare system. 2. Impact of Disaster to the Nation As reported in the World Health Organization (WHO) 3 rd Health Cluster Bulletin, more than 5.6 million people have been affected by this disaster. 1 On the 26 th of May the Disaster Risk Reduction Portal, MoHA reported at least 8,673 deaths and more than 21,952 injures as a result of the 25 th April earthquake and 12 th May aftershock. 2 This number is expected to continue to rise over the coming weeks as further rubble is cleared. Nearly 76,9907 house have been damaged and 4,231 Government facilities completely destoryed. This earthquake has impacted the entire country however 14 districts were notably the hardest hit; Sindhuplachok, Kathamndu, Nuwakot, Dhading, Rasuwa, Gorkha, Kavre, Bhatapur, Lalitpur, Dolakha, Makwanpur, Ramechhap, Solukhumbu and Okhaldunga. Tweleve of these districts are located in the central developmental region and almost all are either mountainous or hilly districts- a challenge for accessibility. 3 1 http://www.who.int/hac/global_health_cluster/countries/health_cluster_bulletin_num3_18may15.pdf?ua=1 2 http://drrportal.gov.np/ 3 http://heoc.mohp.gov.np/health/

The International Organization for Migration (IOM) estimate 2.8 million individuals have been displaced across the 39 affected districts with 75,000 Internally Displaced Persons (IDPs) located within the Kathmandu Valley. 4 Unofficial reporting indicates many IDPs have migrated from Sindhupalchok and Dolakha to Kathmandu Valley. Unofficial data indicates there are 21,601 people living in temporary camps in the Kathmandu Valley across 64 different sites. Outside of official communal camp sites there are a large number of people living under tarpaulins, temporary structures and open sky. Emergency shelter and health assistance are vital in preparation for the impending monsoon season and have been highlighted as priority sectors for intervention. IOM are working in close coordination with the Government of Nepal and humanitarian partners to ensure that displaced populations have access to basic services. The earthquake has severely disrupted the health system and, combined with the public health risks of displacement, puts IDPs at far greater risk of morbidity and mortality, particularly communicable diseases inclusive of TB, practically living in cramped conditions. 5 Real-time updates and in depth details on the overall impact of the disaster is available from the link below: http://drrportal.gov.np/ 3. Impact of Disaster to the Health System: A rapid assessment of health-care facilities by WHO and the Ministry of Health and Population in the earthquake-stricken areas has found that hospitals in 4 of the worstaffected districts are completely destroyed or too badly damaged to function. Five other major hospitals, providing important health care in the districts, were found to be functioning but urgently in need of further medical supplies. Preliminary findings from the assessment, found that while there was a shortage of supplies, sufficient health personnel were available to treat patients arriving in the functioning hospitals. 6 Further assessments from HEOC indicate 1,023 health facilities have sustained full and or partial damage, 7 of the districts hospital are running entirely from temporary hospital tents, with 10 tents spread throughout these 7 districts. To date 8 health workers have died, 63 have been injured and 2 are still missing. 10 Female community health volunteers are been reported dead 4 http://www.iom.int/sites/default/files/press_release/file/iom-nepal-appeal-april-2015.pdf 5 ibid 6 http://who.int/mediacentre/news/releases/2015/health-assessment-nepal/en/

which has great significance in rural areas as these individuals are the ones closest to the community and normally the first point of contact for health related issues. 7 The key challenges following the earthquake is outbreak surveillance and control of communicable diseases inclusive of Tuberculosis, the continuation of treatment for chronic conditions, re-establishment and continuation the general health services that have been destroyed or discontinued in addition to specific services such as maternal and child health and mental health amongst others. Latest situation updates and further details of overall impact of disaster to the Nepali health system is available in the link below: http://heoc.mohp.gov.np/health/ 4. Impact of Disaster to the Tuberculosis Control Program: Rationale for rapid assessment and formation of rapid response committee The challenges Nepal s recent earthquakes pose for the National Tuberculosis Program are significant. In Nepal, TB remains an ongoing public health burden, with health officials keen to ensure that advances in recent years are not threatened. Historically when there is a disaster of high scale, focus is immediately directed towards the rescue and relief efforts and care and control of communicable diseases such as TB are rarely addressed during the acute phase. Literature arising from lesson learn post Haiti and Japan earthquakes indicate the benefit of starting surveillance for TB in the acute phase in TB endemic countries, as there is a high risk of TB silently spreading. 8 This is of particular concern among IDPs where the risk of transmission is higher. 9 With this in mind, the Nepal s National Tuberculosis Centre formed a Rapid Response Committee on the 20 th May 2015 that has set about conducting a Post-Disaster Rapid Assessment of the National Tuberculosis Program for effective management of TB cases and continuation of its services to maintain the achievements of TB program till date. 7 http://heoc.mohp.gov.np/health/ 8 http://www.ncbi.nlm.nih.gov/pubmed/23174381# http://www.researchgate.net/publication/260716753_tuberculosis_control_in_acute_disaster_settings_case_studies_from_t he_2010_haiti_earthquake 9 http://www.ncbi.nlm.nih.gov/pubmed/24581013

The committee has conducted a rapid assessment of the structural damage to and functionality of DOTS and microscopy centers following the earthquake. Refer to Annex A for the district breakdown of the rapid assessment, please find a summary of the impact below, data updated as of 3pm on the 26 th May: Structural impact on and functionality of DOTS centers in the 14 most affected districts: Number of DOTS Centers: 779 Number of DOTS centers fully damaged: 281 Number of DOTS centers partially damaged: 256 Data missing from Lalitpur and Solukhumbu Number of DOTS centers non-functioning: 6 Data missing from Ramechhap, Lalitpur, Kavre and Dhading Number of DOTS centers functioning out of temporary tents: 353 Data missing from Ghorka and Kavre Number of DOTS centres where Drugs completely damaged/unrecoverable: 46 Data missing from Dhading, Rasuwa, Gorkha and Lalitpur Number of DOTS centre where immediate supply of anti-tb medicine was required: 5 Data missing from Gorkha Structural impact on and functionality of microcopy centers in the 14 most affected districts: Number of microcopy centers: 130 Number of microscopy centers non-functioning: 27 Data missing from Solukumbu Please note 10 microcopy centers were not function prior to the earthquake due to human resource shortages. Number of microscopy centre where immediate supply of chemicals was required: 3 Data missing from Solukumbu 5. Impact of Disaster on TB patients: With logistical support from WHO the NTC rapid response committee have started tracing TB patients in the 14 most affected districts, with a priority to reach those with Drug Resistant TB (DR TB). For a district

break down of information refer to Annex A and for a detailed DR TB patient tracing and assessment refer to Annex B. Impact on continuation of Anti-TB Treatment (ATT): Number of TB patients enrolled in ATT on 24 th April: 698 Data missing from Kathmandu, Gorkha, Kavre, Bhaktapur, Lalipur, Dolakha, Makawanpur and Solukhumbu Number of TB patients continuing ATT after 25 th April: 517 Data missing from Sindhupalchowk, Kathmandu, Gorkha, Kavre, Bhaktapur, Lalipur, Dolakha, Makawanpur and Solukhumbu Number of TB patients deceased: 6 Data missing from Solukumbu and Kathmandu Number of TB patients injured: 14 Note: most injuries are minor and all injured TB patients are continuing with ATT Data missing from Solukumbu, Kahtmandu and Sindhupalchowk Number of TB patients who have discontinued ATT: 1 Data missing from Sindhupalchowk, Gorkha, Bhaktapur, Lalipur, Dolakha, Makawanpur and Solukhumbu Number of TB patients who status is unknown: 188 Data missing from Sindhupalchowk, Bhaktapur, Lalipur, Makawanpur and Solukhumbu Impact on TB patients living conditions: Number of TB patients who houses are completely damaged: 220 Data missing from Sindhupalchowk, Nuwakot, Dhading, Rasuwa, Gorkha, Kavre, Lalipur, Dolakha, and Solukhumbu Number of TB patients who are living under temporary shelter (tents): 226 Data missing from Sindhupalchowk, Nuwakot, Dhading, Rasuwa, Gorkha, Kavre, Lalipur, Dolakha, and Solukhumbu Drug-Resistant TB (DR TB) patients: Number of DR TB patients enrolled in ATT on 24 th April: 151 Number of DR TB patients continuing ATT after 25 th April: 134 Number of DR TB patients deceased: 0 Number of DR TB patients injured: 0 Number of DR TB patients who have discontinued ATT: 0

Number of DR TB patients who status is unknown: 16 Number of DR TB patients on clinic-based DOTS: 102 Number of DR TB patients on community-based DOTS: 1 Number of DR TB patients taking ATT by other means: 31 Other means collecting ATT supply of one week or more to be taken at home Number of DR TB patients living in home: 45 Number of DR TB patients living in hostel/hospital: 14 Number of DR TB patients who are living in community temporary shelters: 22 Number of DR TB patients who are living in temporary shelters with family or alone: 26 6. Qualitative analysis of interview with TB heath care workers and TB patients in Bhaktapur District: On 21 May, NTC and WHO staff met with District TB and Leprosy Officers in Bhaktapur to explore issues surrounding post-earthquake TB care and control in the district. The team also met with TB patients living in temporary camps in order to identify patients immediate needs and ensure their continued care and access to treatment. All interview were recorded and consent obtained through verbal translation of informed consent form, which was signed by all participants. Interview with TB health care worker: A guided question interview (refer to annex B) was conducted with one TB health care worker, the District Tuberculosis and Leprosy Officer for Bhaktapur. The 15-minute interview was transcribed and key themes identified: Concern of transmission among internally displaced person in temporary camps There are 109 Tuberculosis patients whose houses are completely damaged, they are living in camps I have concern about the spread of TB in shelters if patients stay 6-8 months in shelter it can be really threatening, shelter for TB patients would be better Difficulty in tracing patients We are in charge of local residents and linked to Kavre and Sindhupalchowk districts, we know of 6 [TB patients] missing in Bhaktapur and 3 in Sindhupalchowk we are trying to track missing patients but mobilization of volunteers to visit their houses is difficult in this scenario.

"We have planned to mobilize health facility management committee member to trace the missing patients" Need for psychosocial counseling "All of the patients are depressed and scared from the earthquake, they need psychosocial counseling to recover Many of the TB health care providers are also depressed and they too need counseling" Interview with TB Patients: A guided question interview (refer to Annex C) was conducted with 2 MDR-TB patients living in temporary camps in Bhaktapur and 1 EPTB patient living a temporary structure alone. The 40- minutes of interviews were transcribed and key themes identified: Patients recognize the importance of continuing ATT after earthquake All patient reported continuing with their ATT. One patient had a six-day supply of anti-tb medicines from before the earthquake as he was attending the Deo Puja festival and did not want to be without his drugs in case clinics were closed for the festival. After the earthquake he continued taking his drugs in the temporary camp. He keeps them safe in a Bhujia (snack) packet as it is waterproof and it protects them from the rain and sun Other patients who did not have a supply of ATT pro-actively sough their medication: The hospital doctor and health worker told me I have to have daily medicine. So I send my wife to go get after the earthquake One patient went to visit the house of a National Anti TB Association scout volunteer known to him: I found her, she had been trapped inside her demolished house. Once she got out, she went back inside the house to get me medicine for 5 days it was important to both of us. Difficulty in adhering to daily DOTS All patients commented on the difficulty in adhering to daily DOTS post-earthquake: My wife goes to get the drugs and I have one week of medication at a time it s difficult to go for daily DOTS, but weekly is easy. We belong to a farming group. We do not have much at this time. If they provide medicine close by it will be easier. The 30 rupees I spend on travel could buy me two eggs to eat.

Increased stigma in temporary camps Patients have expressed experiencing high rates of stigma, especially when trying to secure temporary accommodation in communal temporary camps: The home we were renting collapsed in the earthquake so we tried to go to a shelter. My wife told them about my TB that it was the non-contagious kind but I face much discrimination in the shelter. I think people fear transmission. The people in the shelter shouted to get away and my wife and my two daughters cried a lot. We now stay separately from each other. My wife can only visit one or two times a week. Conclusions from analysis NTC have identified the following key areas of action from the qualitative interview analysis; addressing living conditions of TB patients in temporary camps; increasing patient access to infection control measures and DOTS- through patient centered approaches; minimizing stigma and providing psychosocial support.

Annex A: Post-Disaster Rapid Assessment of National TB Program by District Name of district Structural assessment of DOTS centres Functionally assessment of MCs Situation of TB Drugs at DOTS centres Treatment status of TB patients Living conditions of TB patients Total No Fully damaged Partially damaged Not damaged Nonfunctioning functioning temporarily in tents Status unknown Remarks Total No. Non- Functioning Urgent need of chemical Remarks No. of centre where Drugs completely damaged/ unrecoverable No. of centre where immediate needing supply of TB medicine Remarks Total No of TB patients enrolled in tx before eq Total No. of TB patients still continuing tx after eq Dead Disabled / Injured Discontinued tx Status unknown Remarks House complety damaged Living under temporary shelter (tents) Remark Sindhupalchowk 79 65 1 3 1 75 0 Tatopani HP nonfunctioning as totally damaged and unable to access due to lanslide 4 1 No Non functioning MC's since before eq Jalbire because of lack of HR 44 5 Recent supply sent from NTC 180? 1?? 179 Death in Talamarang HP unable to trace patients as 40% of DOTS centres are uncontactable and staff are focused on eq related trauma, when approached on TB related issues unresponsive as low priority area and do not have means of sending the information eg. fax, telephone, pen & paper?? Kathmandu 115 8 47 0 0 17 totally fucntioning, 2 treatment centers inside the KTM municipality can't be reached cause of bloackage of road. 35 6 25 litre Urgent need to send checmicals Non functioning MC's since before eq 0 0???? 0 3 1 patients went to sindhupalchok before the quake, but didn't come till date for F/u and coudlnt' be traced- Police Hospital 2 others lost from KMC hospital 2 5 3 Living in Tents in school Concerntrated camps in near Dachi Dots Center 2 Houses destroyed in Naglebare, living in Tents Nuwakot 66 41 23 0 2 0 Partially damaged centres still providing services 4 4 No 2 0 Chamari HP- ATT and Register Tukche HP- HRZE 450 Tab, HRE- 250 Tab. 107 107 0 2? 0 Minor injuries only?? Dhading 54 33 17? 8 4 9 8 No Naubishe MC is demolised, Salyantar and Gajuri- Microscope needed? 0 304 303 1 0 0 0 Deceased: Furendra Adhikari, 53,Male, Budhathum- 3?? Rasuwa 19 17 2 0 0 0 Langtang HP- Collapsed, but has no TB patients Haku HP- army take the medicines from DPHO and distribute when they go there, but no TB patients 2 2 10 Litres Urgent need to send checmicals? 0 22 22 0 0 0 0 22 22 Gorkha 71 41 32 67 4? 0 6 2? Arughat PHC Mathi kohla HP- need microscope Kavrepalanchowk 100 35 60??? 14 0 No Panchkhal MC, Destroyed. Working in Tent. (Pradeep Aryal)???? 1 2 0 0 64 63 among 71, 12 TC can't be reached. Among whome reached, all TB patients are accountable. Dead- Thakur purasaini, 75 yrs, Tamrang ward 1 2- Minor Injury 0 0 Not needed?? 0 0 1??? for now. Only to send regular ones Bhaktapur 34 3 4 0 34 0 9 9 No 0 0?? 3 7? 6 Minor Injuries only, Injured pts contining DOTS 109 109 EPTB patient experinced discrimination, living in temporay made shelter on their own Lalitpur 55 2?? 55? 18 3 No Non functioning MC's since before eq 0 0?? 0 0? 0?? Dolakha 56 1 9 1 54 0 Lamabagar HP- Non functioning 6 5 10 Litres Urgent need to send checmicals? 0 All 70 sites Exact Status N/A on medicine, 20-30% presumed lost all drugs 45 45 0 1 0 0 Injured:Saila Shrestha, Bhote naglang?? Makawanpur 43 10 33 0 43 0 6 0 No 0 0?? 0 2?? Injured pts continuing DOTS 0 4 Ramechhap 56 25 28 3 53 0 6 6 No 0 0 40 40 0 0 0 0 23 23 Solukhumbu 17?? 0 17 0 7?? 0 0?????? 0 0 Okhaldhunga 14?? 0 12 0 4?? 0 0????????

Annex B: Post-Disaster DR TB Patient Tracing and Assessment Treatment 1=Clinic, 2= Family, 3= Community based, 4=Other (please explain) Treatment centre Housing status In tent Type of Type of reason, In tent at with At Discontinued Status Continuing DOTS pre DOTS post Tx centre pre Tx centre post if community family/ hostel/ At S.N Death Injured Tx Unknown Tx earthquake earthquake earthquake earthquake moved camp alone hopital Home Other Unknown 1 1 1 1 GENETUP GENETUP 1 2 1 1 1 STUPA STUPA 3 1 1 1 STUPA STUPA 4 1 1 1 GENETUP GENETUP 1 5 1 1 1 GENETUP GENETUP 1 6 1 7 1 8 1 1 1 NATA Hostel NATA Hostel 1 9 1 1 1 STUPA STUPA 10 1 1 1 NATA Hostel NATA Hostel 1 11 1 1 1 GENETUP GENETUP 1 12 1 1 1 GENETUP GENETUP 1 13 1 1 1 STUPA STUPA 1 14 1 1 1 STUPA STUPA 1 15 1 1 1 NATA Hostel NATA Hostel 1 16 1 1 1 GENETUP GENETUP 1 17 1 1 1 GENETUP GENETUP 1 18 1 1 1 Kharini PHC Kharini PHC 1 19 1 1 1 GENETUP GENETUP 1 20 1 21 1 1 4 GENETUP GENETUP 1 22 1 1 1 NATA hostel NATA hostel 1 23 1 1 4 GENETUP GENETUP 1 24 1 1 1 GENETUP GENETUP 1 25 1 1 1 STUPA STUPA 1 26 1 1 1 helping handsstupa helping handsstupa 1 27 1 1 1 DPHO Clinic DPHO Clinic 1 28 1 1 1 DPHO Clinic DPHO Clinic 1 29 1 1 4 DPHO Clinic DPHO Clinic 1 30 1 1 1 DPHO Clinic DPHO Clinic 1 31 1 1 1 DPHO Clinic DPHO Clinic 1 32 1 1 4 DPHO Clinic DPHO Clinic 1 33 1 1 4 DPHO Clinic DPHO Clinic 1 34 1 1 1 DPHO Clinic DPHO Clinic 1 35 1 1 1 DPHO Clinic DPHO Clinic 1 36 1 1 4 DPHO Clinic DPHO Clinic 1 37 1 1 1 Patan Hospital Patan Hospital 1 38 1 1 1 Patan Hospital Patan Hospital 1 39 1 1 1 Patan Hospital Patan Hospital 1 40 1 1 1 Patan Hospital Patan Hospital 1 41 1 1 1 Kalimati Hostel Patan Hospital 1 42 1 1 1 Patan Hospital Patan Hospital 1 43 1 1 1 Patan Hospital Patan Hospital 1 44 1 1 4 Patan Hospital Patan Hospital 1 45 1 1 1 Patan Hospital Patan Hospital 1 46 1 1 1 Patan Hospital Patan Hospital 1 47 1 1 1 Patan Hospital Patan Hospital 1 48 1 3 3 Patan Hospital Patan Hospital 1 49 1 1 4 Khopasi PHC Khopasi PHC 1 50 1 1 4 Barabishe PHC Barabishe PHC 1 51 1 1 4 Barabishe PHC Barabishe PHC 1 52 1 1 4 Barabishe PHC Barabishe PHC 1 53 1 1 1 Mission Hospital Mission Hospital 1 54 1 1 Mission Hospital Mission Hospital 1 55 1 1 4 DHO Makwanpur DHO Makwanpur 1 56 1 1 4 DHO Makwanpur DHO Makwanpur 1 57 1 1 4 DHO Makwanpur DHO Makwanpur 1 58 1 1 4 DHO Makwanpur DHO Makwanpur 1 59 1 1 4 DHO Makwanpur DHO Makwanpur 1 60 1 1 4 DHO Makwanpur DHO Makwanpur 1 61 1 1 4 GENETUP GENETUP 1 62 1 1 GENETUP GENETUP 1 63 1 1 1 Dhading 1 64 1 1 1 GENETUP GENETUP 1 65 1 1 1 RTC RTC 66 1 1 1 NATA Hostel NATA Hostel 1 67 1 1 1 STUPA STUPA 1 68 1 1 1 Khairini PHC Khairini PHC 1 69 1 1 1 GENETUP 1 70 1 1 1 Bir Hospital Bir Hospital 1 71 1 1 1 GENETUP 1 72 1 1 1 GENETUP 1 73 1 1 1 GENETUP 1 74 1 1 1 GENETUP 1 75 1 1 1 NMC NMC 76 1 1 1 GENETUP 1 77 1 1 1 NMC NMC 78 1 1 1 KHAIRENI PHC KHAIRENI PHC 1 79 1 1 1 GENETUP GENETUP 1 80 1 1 1 GENETUP GENETUP 1 81 1 1 4 GENETUP GENETUP 1 82 1 1 1 GENETUP GENETUP 1 83 1 1 1 84 1 85 1 86 1 1 1 BIR HOSP BIR HOSP 1 87 1 1 1 GENETUP 1 88 1 1 1 GENETUP 1 89 1 1 1 GENETUP 1 90 1 1 1 KHAIRENI KHAIRENI 1 91 1 1 1 Bharatpur Bharatpur 1 92 93 1 1 1 1 Dhading GENETUP 1 94 1 1 1 BIR HOSP BIR HOSP 1 95 1 1 1 GENETUP GENETUP 1 96 1 1 1 KHAIRENI PHC KHAIRENI PHC 1 97 1 98 1 1 1 KHAIRENI PHC KHAIRENI PHC 1 99 100 1 1 1 GENETUP GENETUP 1 101 1 1 1 NMC NMC 1 102 1 103 1 1 4 GENETUP GENETUP 1 104 1 1 1 GENETUP GENETUP 1 105 1 1 1 STUPA STUPA 106 1 1 1 STUPA STUPA 107 1 1 1 GENETUP GENETUP 1

108 1 109 1 1 1 Bharatpur Bharatpur 1 110 1 1 4 GENETUP GENETUP 1 11 1 112 1 1 113 1 1 1 GENETUP GENETUP 1 114 1 1 1 NMC NMC 115 1 1 116 1 1 1 STUPA STUPA 1 117 1 1 4 1 118 1 1 1 STUPA STUPA 1 119 1 120 1 121 1 1 4 1 122 1 1 1 Bharatpur Bharatpur 1 123 1 124 1 GENETUP 1 125 1 NMC 1 1 NMC 126 1 1 1 NATA Hostel NATA Hostel 1 127 1 128 1 129 1 1 1 STUPA STUPA 1 130 1 131 1 1 4 Bir hospital 1 132 1 1 1 Dhading Dhading 1 133 1 1 1 NATA Hostel NATA Hostel 1 134 1 1 1 NATA Hostel NATA Hostel 1 135 1 1 1 GENETUP GENETUP 1 136 137 1 1 1 DHADING DHADING 1 138 139 1 1 1 KHAIRANI KHAIRANI 1 PHC PHC 1 140 1 1 1 GENETUP GENETUP 1 141 1 1 1 KHAIRENI PHC KHAIRENI PHC 1 142 1 1 1 Helping Hands Helping Hands 1 143 1 1 1 Bharatpur Bharatpur 1 144 1 1 1 STUPA STUPA 145 1 1 1 KHAIRANI PHC KHAIRANI PHC 1 146 1 1 1 Bharatpur Bharatpur 1 147 1 1 1 GENETUP Hostel GENETUP Hostel 1 148 1 1 1 Helping Hands Helping Hands 1 149 1 1 4 GENETUP TB Nepal 1 150 1 1 1 GENETUP GENETUP 1 151 1 1 1 GENETUP GENETUP 1 134 22 0 0 0 17 0 26 14 45 8 2 Please note patient names have been removed to retain patient confidentially

Annex C: Guided Interview Questions For TB patient: 1) How and from where are you obtaining your anti-tb medication? 2) Have you had any disruption to your treatment, if so, for how long? 3) What are your living conditions post earthquake? 4) How are you managing your nutrition after the earthquake? 5) Have you experienced any discrimination/stigma? e.g. do you have any difficulty in sharing a tent or meals with other people? 6) Do you have access to face masks and other infection control measures? 7) How to you think DOTS services should be provided post earthquake? 8) Have you been advised on your future treatment plan? i.e. where you will continue to get medicines etc. For TB health care worker: 1) How soon after the earthquake did you go back to work? 2) Have you been able to work normal hours? 3) Has there been anything preventing you from working? If so please explain i.e. lack of medicines, no running water, no electricity, no patients, family issues 4) Do you have any missing patients? 5) Do you have any concern about how DOTS will run in the future? How do you think it should run? 6) What are you doing for suspected TB cases? How are you diagnosing patients? i.e. clinically, microscopy, GeneXpert etc.