Battle against TB continues despite recent successes

from Reuters Alert Net

DHAKA, Abdul Ali Sardar, a fisherman in southern Bangladesh, never thought he would survive tuberculosis (TB).

"One year ago, I caught a cold after returning home from a night of fishing along the Kirtankhola river. The cough continued for more than a month. Then came the fever. It would come every evening just before going out on the river for fishing," the 30-year-old recalled.

"I couldn't go out fishing. We poor people don't have the luxury of sitting at home without working," he said, lying on his bed at the Directly Observed Therapy Shortcourse (DOTS) centre (which specialises in TB treatment) at the Sher-e-Bangla medical college in the southern city of Barisal.

Arriving in critical condition just three weeks earlier, Abdul is now on the road to recovery, but only after visiting a variety of quacks and soothsayers over a six-month period.

"He came here very late, [but] only after exhausting all traditional and folk treatment which simply complicated his case. He wouldn't have suffered so much had he come to our centre earlier," said Burhanul Kibria, supervisor of the DOTS centre.

"I hope he will be able to return home after two weeks. Patients do not require to be hospitalised nowadays. Outpatient treatment is enough," he said, describing Abdul's case as a glaring example of how effective DOTS therapy can be.

TB is still a major public health concern in Bangladesh, one of the most densely populated and impoverished countries in the world.

According to the World Health Organization (WHO), an estimated 300,000 new cases occur annually, with some 70,000 deaths per year [http://www.whoban.org/communicable_dis_tb.html].

Bangladesh is ranked fifth on the list of 22 high TB prevalent countries in the world, government sources say.

Link with poverty

Latest estimates from the country's National Tuberculosis Control Programme (NTCP) reveal there are 875 new cases of infection and 180 deaths daily.

Yet like most low-income countries, it is the poorest of the poor that suffer the most from such diseases.

A 2000-2001 study by the NTCP showed up to 70 percent of the patients attending DOTS centres were living below the poverty line - on under one dollar a day.

At the same time, the value of the lost personal income income as a result of TB is almost three times a patient's average monthly household expenditure, the study said.

Equally disturbing is the fact that 20 percent of the patients who were above the poverty line when they first contracted the disease were pushed into poverty as a direct result of the cost of their disease.

Detection success

Bangladesh adopted the DOTS strategy in 1993. Since then the case-detection rate for new smear positive cases (a case of TB where mycobacterium tuberculosis bacilli are visible in the patient's sputum when examined under the microscope) increased gradually and reached 28 percent in 1998.

Until 2001 only marginal progress had been achieved in terms of further increasing the case-detection rate.

From then onwards, case detection accelerated to reach 46 percent in 2004 and further increased to 61 percent in 2005 and 71 percent in 2006, thereby reaching the global target.

A total of 145,215 cases, or 103 per 100,000 persons, were reported to the NTCP in 2006.

"At present the case detection rate is 72 percent. This phenomenal increase in case detection would not be possible without strong commitment from all stakeholders, consistent funding and a strengthened and expanded collaboration between governmental and non-governmental - both national and international - allied organisations," said an optimistic Probhat Chandra Barua, director of the government's Mycobacterium Disease Control and TB and Leprosy programme.

Private medical practitioners play a major role in TB care in Bangladesh. During the initial stages of the disease, 60-70 percent of TB patients report to private practitioners for diagnosis and treatment.

Drug-resistant TB

Thirty five countries, including Bangladesh, now have confirmed drug-resistant TB cases, according to the WHO.

In fact, in Bangladesh 1.02 percent of TB patients are infected with drug resistant strains.

Drug-resistant TB is caused by inconsistent or partial treatment, when patients fail to take their medication regularly for the prescribed period because they start to feel better, because doctors and health workers prescribe the wrong treatment regimens, or because the drug supply is unreliable.

A particularly dangerous form of drug-resistant TB is multi-drug resistant TB (MDR-TB).

"While drug-resistant TB is generally treatable, it requires extensive chemotherapy [with] up to two years of treatment with second-line anti-TB drugs which are more costly than first-line drugs, and which produce adverse drug reactions that are more severe," AKM Ahsan Ali, chairman of Community Participation for Health and Development (CPHD), a local non-governmental organisation (NGO) that has been working in this field for over a decade, explained.

"The cost of treatment of MDR-TB is 10 times more than normal TB cases," he said.

According to the WHO, one in 10 new infections is resistant to at least one anti-tuberculosis drug.

In Bangladesh, antibiotics are sold over the counter, while in rural parts of the country, the first visit of a patient is usually to the local doctor who might prescribe an array of antibiotics for a particular ailment.

Sometimes, the patient chooses his or her own antibiotics which the drug store provides without asking any questions. In many cases patients do not complete their full course of antibiotic medication.

"This gradually creates drug-resistance among TB germs. When these germs infect other people, antibiotics fail to kill those germs. Here lies the potential danger," Shahid Hasan, a senior journalist who works as a volunteer with CPHD, noted.

Free treatment

To address that, TB diagnostic and treatment services are now offered free of charge under the NTCP in 853 facilities, including all 481 sub-district health facilities and 308 municipalities. In fact, 99 percent of the country's more than 150 million inhabitants live in areas where DOTS services are now available.

"The DOTS target is identification of 70 percent of patients and Bangladesh has identified 72 percent as of December 2007. Ninety-five percent of those who receive treatment from us get cured," said NTCP director Barua.

"There is full commitment from the government. The private sector is enthusiastically involved in the DOTS programme. The Global Fund To Fight AIDS, TB and Malaria is generous in providing funds to the government. WHO provides technical support and BRAC (a national NGO that reaches out to all villages of Bangladesh) works on the ground to identify and treat TB patients," he said.