TB in South-East Asia

Country Profiles: Bangladesh

With a population of 150 million, Bangladesh ranks sixth among countries with a high TB burden. The estimated prevalence and incidence rates of all forms of tuberculosis were respectively 387 and 223 per 100 000 population, in 2007. TB control activities were further expanded by increasing the number of peripheral laboratories, sputum collection or smearing centres so that access to TB diagnostic services improved. The case-detection rate increased to 73% in 2007*. The reported treatment success rate has increased to 92% for the cohort of patients registered in 2006. The National TB Guidelines were updated bringing national policies in line with more recent international recommendations. A nationwide disease prevalence survey is being conducted to establish more accurate estimates of the prevalence of tuberculosis and to assess the trend of the epidemic in the country.

Community-based DOTS through village doctors and BRAC’s network of shasthya shebikas (community health volunteers) is the most common echanism

for supervising drug intake. Collaboration with garments’ manufacturers—with three million employees and one of the largest industrial sectors—was formalized and plans developed for providing TB services in these companies.

Data from national drug resistance surveys indicate low levels of MDR-TB. A population-based survey is planned in 2009 to evaluate the magnitude of drug resistance. Isolated surveys have indicated that MDR-TB rates among newly diagnosed cases range between 0.4% and 3% and among previously treated cases, between 3% and 15.4%. A limited survey of drug susceptibility among patients failing category II regimens showed that 88% had MDR-TB. The National Tuberculosis Reference Laboratory was accredited for culture and DST by the Supranational Reference Laboratory in Bangkok in 2007. One regional reference laboratory has been set up in Rajshahi division and two additional regional reference laboratories are planned to be established during 2009-2010.

The first hundred MDR-TB patients were enrolled in a GLC-approved DOTS-Plus pilot project at the National Institute of Diseases of Chest and Hospital, Dhaka, while Damien Foundation extended its support for MDR-TB case management to cover an additional 30 million population.

HIV prevalence in the adult population (15-49 years) and the proportion of HIV positive individuals among TB cases has been estimated to be low at 0.02% and 0.1% respectively. A recent survey revealed an HIV prevalence of 7% among injecting drug users. This has raised concerns regarding the potential for transmission of HIV to other population groups. National TB/HIV guidelines have been developed. While a national TB/HIV committee is now functional, collaboration between the two programmes needs to be strengthened. A limited number of NGOs provide HIV counseling, prevention and care for TB-HIV co-infected individuals.

TB services are part of an essential services package under the sectorwide health, nutrition and population sector programme (HNPSP) which is implemented through the primary health care system of the country. Bangladesh is an outstanding example of implementing TB control in partnership with NGOs. Several private and corporate sectors are involved in TB control and in rendering services in line with international standards for TB care. Thirty seven public hospitals including medical college hospitals and military hospitals have been involved so far. Services have also been established in the prison system. The data management software has been upgraded. NTP and NGO staff is being trained in data analysis and use for programme management and development. An HRD plan has been developed and a focal point for HR designated at the central level.

The TB programme benefits from Global Fund support through Rounds 3 and 5. This support is channelled through two principal recipients: the External Resource Division (ERD) of the Ministry of Finance (MoF) and BRAC. WHO provided strong technical and operational support to the programme. In addition, USAID has been providing financial assistance to NTP directly while several other donors are funding TB activities through NGOs. Some support for TB control is also made available through the HNPSP.

Major Achievements

     Enhanced quality of laboratory services;

     Establishment of a national MDR-TB coordination committee, clinical management, social support committee and laboratory working groups;

     Improved coordination and collaboration between NGO partners and between the government and NGOs;

      “Managing Information for Action” (MIFA) courses held for central and district level staff;

     Scaling up of public-private partnership (PPP) and involvement of civil society and community;

     Improved drug management through implementation of SOPs; and

     Improvements in data management software.

Major challenges and constraints

     Sustaining the quality of DOTS;

     Maintaining implementation in the face of high turnover of government and NGO staff;

     Scaling up the management of MDR-TB;

     Building linkages with the National AIDS and STI programme for TB/HIV;

     Further scaling up and strengthening PPP;

     Addressing drug management issues that have led to emergency procurements; and

     Lack of sufficient supportive supervision

     Enhancing evidence-based programme management

Planned activities

     Finalizing the national TB/HIV operational guidelines;

     Phase-wise expansion of TB/HIV collaborative activities;

     National HIV prevalence survey among TB patients in 2009;

     HR development for wider implementation of TB/HIV, MDR-TB and PPM DOTS interventions;

     Upgrading regional reference laboratories for culture and drug susceptibility testing;

     Undertaking national drug resistance survey in 2009;

     Gradual expansion of PPM activities;

     Strengthening the procurement and supply management system;

     Strengthening supervision and monitoring;

     Scaling up of comprehensive Advocacy, communication and social mobilization (ACSM) activities;

     Curricula development/implementation for under graduate/post graduate medical, paramedical and nursing students on DOTS, TB/HIV, MDR-TB.

     Conducting an assessment of the impact of the IEC campaigns on the population and service recipients; and

     Continued operational research for programme development.

TB epidemiological profile, Bangladesh

TB Unit of the WHO Regional Office for South-East Asia

* The new smear positive case detection rate is 73% when calculated using the most recent national population figure which is 143 million.