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Improving the Tuberculosis situation in selected urban areas of Bangladesh with special emphasis on slums, marginalized populations, and gender

Children in Dhaka, Bangladesh, search at a local garbage dump for trash that they can sell. © 2015 Probal Rashid, Courtesy of Photoshare

Research Overview

TRAction is funding research conducted at the International Center for Diarrheal Disease Research, Bangladesh (icddr,b) examining the effectiveness of tuberculosis (TB) interventions and services in urban areas of Bangladesh, with particular emphasis on slum populations.  With three main objectives examining constraints to treatment coverage and case detection, understanding modes of transmission was of particular concern as a path toward mitigating the incidence of drug-resistant cases. 

According to the WHO, among 22 countries where TB is considered “high burden,” Bangladesh is ranked 6thwith a mortality rate of 45/100,000 and an incidence rate of 225/100,000 annually.  The National Tuberculosis Control Program (NTP) is credited with implementing directly observed therapy short course (DOTS) countrywide as of 2006 with an impressive 92% treatment success rate.  Though the country has met WHO’s case detection rate of 74%, only 14% of cases are located in urban areas and of those recorded, they are disproportionately male.  This calls into question potential barriers and facilitators to both detection and treatment in urban areas, especially among vulnerable populations.

Successes in controlling TB belie gaps in coverage and may also represent gaps in reporting.  Some researchers hypothesize that cases may be under reported because, particularly in urban areas, private clinics are treating patients with TB but, being outside the purview of the NTP, are not required to report cases nor are they included in the country’s DOTS-related capacity building efforts.  When coupled with unique factors to living in urban slums, identifying barriers to access among these populations can be quite complex and warrants further exploration for Bangladesh to reduce the burden that TB places on the health of its population.

Study Location

Bangladesh: Dhaka

Research Objectives

Primary Objective: To assist stakeholders with understanding barriers to implementing appropriate intervention strategies so as to strengthen TB services in urban areas.

Secondary objectives:

  1. To document the current TB situation and control measures in urban areas with special attention to slum populations,
  2. To test intervention packages along existing TB control activities to improve case detection, improve access to TB diagnosis, increase notification, referral and treatment outcome,
  3. To increase the number of cases detected including drug resistant cases of TB by active screening and using sensitive diagnostic GeneXpert MTB/RIF Assay,
  4. To characterize clinical isolates of Mycobacterium tuberculosis prevailing in the urban community so as to understand the mode of transmission.

Study Approach

Researchers employed a mixed methods, cross-sectional approach. 300,000 participants were selected into the study from one of three clinics (Mugdapara, Tejgaon, and Mirpur-11) located in Dhaka City.  The interventions involved attempts at improving case detection, retention, and notification through a package of training segments, procedural changes (e.g. identifying cases with a cough for more than 2 weeks rather than 3), and innovative interventions (e.g. using mobile phones to improve compliance).  Data collection for the qualitative component involved focus group discussions, key informant interviews, and observational data from a standardized checklist.  The quantitative component comprised a cross-sectional survey that gathered information on the clinic staff/DOTS team, the DOTS Unit, availability of the NTP manual and related documentation, lab facilities’ quality, and a household questionnaire.

Key Findings

This study revealed several key findings that will help to strengthen future TB control efforts in urban areas. Two-sample sputum is equally good as the three-sample testing for detection of TB. With active case finding, the number of TB suspects increased, and case detection increased by 12% from the baseline. The case detection rate was 84% (compared to national rate of 68%) among persons of reproductive age (15-54 years), with male: female ratio of 1.1:1 (compared to national ratio of 1.6:1).  Finally, a considerable number of smear-negative TB cases were identified by GXP (positivity 4.2% among smear-negative samples).

Lessons Learned

A single visit at every household in a year, integrated with ongoing DOTS activities in this congested setting, increased TB case detection by 12% compared to baseline and helped in limiting TB transmission by early case detection and treatment initiation. Active door-to-door screening at every household at least once in a year should be implemented by Government to improve diagnosis and treatment outcomes of TB in high-risk populations like urban slum dwellers. However, training duration and quality was inadequate for DOTS-specific personnel and could be a contributing factor to staff shortages.  In addition, human resource constraints existed, hindering detection efforts and warranting investments in more field workers. There is a need for separate sitting space for TB patients receiving DOTS services; and

Research into Action

The study’s results will be helpful for improving the design of TB control activities in urban areas.   This study will also provide evidence in the form of feedback to improve the operation of the NTP and toward improving the function of TB control activities.

Implemented by 

International Centre for Diarrheal Disease Research (icddr,b)

Principle Investigator: Dr. K. Zaman

Project Status

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