Bangladesh needs to address growing multidrug-resistance tuberculosis

On this World Tuberculosis Day, the World Health Organization (WHO) observes that 49 million lives were saved worldwide through effective diagnosis and treatment of tuberculosis between 2000 and 2015.

However, around 480,000 people globally have developed multidrug-resistant tuberculosis (MDR-TB) in 2015, which is a cause for concern for Bangladesh as a high MDR-TB burden country. MDR-TB prevalence in Bangladesh was 1.4% among new and 28.5% in previously treated patients, according to the most recent nationwide survey.

People with MDR TB may be increasing in Bangladesh. Photo: Mark Blonk / icddr,b

A recent icddr,b sentinel surveillance has also indicated that the number of new MDR-TB patients in Bangladesh may be even higher.

The findings, published in The International Journal of Tuberculosis and Lung Disease, have shown MDR-TB to be prevalent among 2.3% new patients and 13.8% patients who were previously treated for TB.

“The finding is worrisome as it indicates that new patients with MDR-TB could have doubled in comparison with the last nationwide survey,’ says Dr Sayera Banu, principal investigator the study and senior scientist and acting head of emerging infections programme at icddr,b.

The new findings however, may not be epidemiologically representative of the whole country. Samples for this surveillance were collected from fourteen sentinel surveillance sites (hospitals) across seven divisions in Bangladesh over four years and maybe regarded as a reliable estimate of the country situation, mentions the study funded by USAID through CDC.

“Expanding sentinel surveillance to a broader network across the country will allow closer estimations of true MDR-TB burden in Bangladesh,” says Dr Banu. And this requires continuous national MDR-TB surveillance, which many of the 27 high MDR-TB burden countries have already established by 2013.

On the second year of the two-year campaign themed ‘Unite to End TB,’ the WHO aims to raise awareness around ‘Leave no one behind’ – an approach to ensure health services for everyone including those out of reach of the health system. The WHO considers it essential for fulfilling the goal of ending TB by 2030, as part of the UN SDGs and the WHO End TB Strategy.

In Bangladesh, icddr,b researchers are in the frontline of fighting the spread of TB with over two-decades of research and the most recent TB diagnosis initiative at its own screening centres (TBSCs).


The next frontier for tuberculosis care in Bangladesh

icddr,b has set a track record of conducting over 50 TB studies notably in children, rural environment and among high-risk groups such as prisons, or in areas more prone to disease transmission such as urban slums.

In recent years, icddr,b’s three TB screening centres (TBSCs)  in Dhaka continue to work on early detection of TB using advanced diagnostics like GeneXpert. These TBSCs also ensure free treatment through DOTS (directly observed treatment, short-course) as part of a social enterprise initiative and public-private partnership.

icddr,b is expanding TBSCs in Dhaka and across the country. Photo: Mark Blonk / icddr,b

According to WHO Global Tuberculosis Report 2016, an estimated 10.4 million new TB cases were found worldwide in 2015, of which 4.3 million cases are either unreported or undiagnosed. Bangladesh is among the ten countries that accounts for 77% of this total estimated gap.

With the mission to address this gap, the screening centres spearheaded by Dr Banu aim to detect these unreported and undiagnosed cases, which is key to controlling the infectious disease. MDR-TB is defined as resistance to two anti-TB medications: rifampicin and isoniazid. These TBSCs centres use state-of-the-art diagnostic called GeneXpert that can identify rifampicin-resistant TB (RR-TB) cases in two hours, which is a valid marker for MDR-TB suspects. WHO recommends that all patients with RR-TB are treated with a second-line MDR-TB regimen.

The screening centres are actively working to identify underreported TB cases to aid the National Tuberculosis Control Program (NTP). In 2014, Bangladesh Government issued a gadget notifying all doctors to mandatorily report confirmed TB patients to the NTP. This, however, lacked on-the-ground implementation.

At present, icddr,b’s screening centres are bridging the gap by networking with thousands of doctors so that TB suspects are referred to the screening centres for confirming the cases. The screening centres then report to the NTP, which otherwise would not have the accurate data on confirmed patients.

“We are expanding the screening centres in Dhaka and other parts of the country with higher TB burden,” says Dr Banu.

In 2016, icddr,b became a sub-grantee of the Global Fund to Fight AIDS, Tuberculosis and Malaria under the NTP to work on lowering TB by 6% by 2017. With this milestone, the screening centres now provide treatment for free in addition to its existing modality as TB diagnostic facility. icddr,b TBSCDOTS program operates beyond the conventional time (8am - 2pm) of other DOTS facilities and offers evening DOTS to attract those who find it difficult to visit DOTS during daytime. Dr Banu’s team is now working on developing an m-health platform to enhance TB case reporting.