Progress and Challenges in TB Control Programme

CHIEF GUEST:

Prof Dr Md Shamiul Islam, Director, MBDC and Line Director TB-Lep and ASP, Directorate General of Health Services

MODERATOR:

Shamim Ahmed, Doctoral Researcher, University of Toronto

WELCOME SPEECH:

Dr Mahfuza Rifat, Associate Director, TB Control Programme, BRAC

Discussants:

Dr Iqbal Arslan, Professor, Biochemistry and Molecular Biology and Former Dean, BSMMU

M A Faiz, Professor-Medicine, Sir Salimullah Medical College and Former Director, DGHS

Dr Md Akramul Islam, Director-Communicable Diseases and WASH, BRAC

Dr Nazis Arefin Saki, Medical Officer, National Tuberculosis Control Program (NTP), DGHS

Shishir Moral, Journalist, Prothom Alo

Syed Abul Maksud, Writer and Social Activist

Dr Rupali Sisir Banu, National Programme Coordinator, NTP, DGHS

Jewel Aich, Magician

Dr Shakil Ahmed, Professor of Paediatrics, Shaheed Suhrawardy Medical College

Tropa Majumdar, Director, Expressions Ltd

Syed Ishtiaque Reza, Editor in Chief, GTV

Monjurul Ahsan Bulbul, Editor in Chief, TV Today

Dr Ejajul Islam, Head, Department of Nuclear Medicine, Dhaka Medical College

Maya Vandenent, Chief of Health Section, UNICEF Bangladesh

Xeres Sidhwa, Director-Health, USAID

Dr Ahmadul Hasan Khan, Monitoring & Evaluation Expert, National TB Control Programme

Chayanika Chowdhury, Writer and Director (Film and Drama)

Sumaiya Shimu, Actress and Founder & Chairman, Better Future Communication

Dr Asif Mujtaba Mahmud, Consultant, Respiratory Medicine, Asgar Ali Hospital

Dr M A Hamid Salim, Global Fund/MDR-TB Advisor, National Tuberculosis Control Programme (NTP) Bangladesh

Munmun Ahmed, Dance Artist and Actress

Dr Mya Sapal Ngun, Medical Officer-Communicable Diseases Surveillance, World Health Organization, Bangladesh

Dr Sabera Sultana, National Professional Officer-Neglected Tropical Diseases and Hepatitis, World Health Organization, Bangladesh

Prof Dr Md Shahedur Rahman Khan, Director, NIDCH

Dr Mahfuza Rifat, Associate Director, TB Control Programme, BRAC

Tuberculosis (TB) is a global public health issue, with Bangladesh being among the 30 high burden TB countries. TB is not only a clinical concern but also a disease affected by social determinants. National Tuberculosis Control Program (NTP) is working with partners to combat TB. The case detection of TB increased from 40 to more than 70 percent in the last two to three decades, and this change was made by collaborative actions at all levels by engaging different sectors. NGOs such as BRAC, Damien Foundation, came forward to support scaling up of services through community-based approach. We need to work more to reach the last miles of TB control by sustaining the momentum and through engaging different sectors in TB.

Dr Nazis Arefin Saki, Medical Officer, National Tuberculosis Control Program (NTP), DGHS

According to the Global Tuberculosis Report 2019, 47,000 people die of TB in Bangladesh every year. The estimated incidence rate is 221 per 100,000 people. NTP aims to reduce the number of TB deaths in Bangladesh by 35 percent by 2020 (from 72,450 in 2015 to 47,092 in 2020). Bangladesh has already met the 2020 TB mortality target, but the incidence rate is not declining much. Case identification, however, is increasing significantly.

Our recent survey shows that the prevalence of all forms of TB is 260 per 100,000 people. In 2019, we identified 82 percent (292,000) of TB cases, with around 86,000 missing. In 2003, we achieved the global target for treatment success rate and have sustained it until now.

Specialised child TB centres have been established, capacity building is ongoing, and new child-friendly dispersible drugs with fruity flavour have been introduced. The expected trend is that 10 percent of total diagnosed TB cases will be of child TB but in 2019, we only identified 4.22 percent.

In 2017, the GeneXpert services were expanded, resulting in a 40 percent increase in case detection in the past two years. Hence, more drug-resistant TB cases have been diagnosed. Currently, there are two different types of treatments for drug-resistant TB: the shorter regimen of nine months, globally known as the Bangladesh regimen, and the longer regimen. Bangladesh has been maintaining an 80 percent treatment success rate for MDR TB.

Two new drugs, bedaquiline and delamanid, introduced for MDR TB and extensively drug-resistant tuberculosis (XDR TB) management in 2016, have caused treatment success rates to go up from 25 to 81 percent. Challenge remains in human resources and funding. 

Shishir Moral, Journalist, Prothom Alo

Private practitioners are not reporting to NTP properly. Many people obtain treatment from outside the formal sector that needs consideration. An estimation of the number of treated patients in the private sector is necessary to understand the scenario.

Syed Abul Maksud, Writer and Social Activist

Extra-pulmonary TB cases such as gland and bone TB are rampant in our country, which requires social awareness.

Since TB is not a reason for mass fear anymore, it is not being talked about much in recent times. District-level hospitals should have separate TB cells. Moreover, contextual research is required, with focus on our socio-economic status relating to TB.

Dr Rupali Sisir Banu, National Programme Coordinator, NTP, DGHS

Diagnosing child TB is difficult since children cannot provide cough for tests and this causes complications in the sputum test of GeneXpert machines. Intensive care management, including gastric lavage, is required at district and upazila levels. Keeping this in mind, NTP has opened five specialised child TB centres in Dhaka Shishu Hospital, Dhaka Medical College Hospital, Institute of Child and Mother Health (ICMH), etc.  

The mandatory notification gazette from the Government in 2014 should be used by the private sector to report TB cases.

Jewel Aich, Magician

Child TB could be an area to work on along with other childhood diseases. Also, breaking myths encircling TB is very important. There was a myth about playing the flute, that led to people becoming infected with TB. Coincidentally, the boy I used to learn to play the flute with during my childhood actually was infected with TB. However, I now I believe that his disease was due to his dire living conditions and poor nutrition and not for playing the flute.

Dr Shakil Ahmed, Professor of Paediatrics, Shaheed Suhrawardy Medical College

Nearly 37 to 40 percent of all missing TB cases are childhood TB, which should be addressed more vigorously. The general people should be aware that TB is a disease that affects both adults and children. Children in households living with adult TB patients are also prone to contracting TB and need to be checked. Other family members can prevent being infected by taking a six-month oral medication course, even if they do not display any symptoms.

Tropa Majumdar, Director, Expressions Ltd

We have lost urgency when it comes to the spirit of "It's Time to End TB". Enhancing communication to revive it is necessary. The mass listens when celebrities speak up, but further initiatives are required such as designing communication campaigns and engaging those we wish to address and cure.

Syed Ishtiaque Reza, Editor in Chief, GTV

The health sector creates many simplified TVCs on TB awareness, but other private channels are not interested in running these TVCs. Television owners should be included in future stakeholders' meetings.

Identifying how much investment is going into TB control is important, to make the return on these investments clearer for those involved in journalism.

Monjurul Ahsan Bulbul, Editor in Chief, TV Today

Breaking the culture of secrecy and stigma is very important for increased TB detection. Media engagement can play an important role in message development.

The quality of campaign in social media must be enhanced and the presentation style could be revisited. Effective communication strategy is important in this regard.

Ethical involvement of civil society organisations is also crucial.

Dr Ejajul Islam, Head, Department of Nuclear Medicine, Dhaka Medical College

Advertisers need to be careful about how they present information regarding TB and remind people that they need to be responsible and complete the full course of medication to recover from TB.

Out of 10 pharmacies, only five have qualified pharmacists. Pharmacists need to refer symptomatic patients to Government/NGO designated TB centres. The majority of patients go to pharmacists in unions instead of visiting qualified doctors. The fact that these pharmacists are now treating billions of patients should be under the consideration of NTP.

Maya Vandenent, Chief-Health Section, UNICEF Bangladesh

Bangladesh has a very successful but expensive primary healthcare system. Community clinics, Family Welfare Assistants (FWAs), and Health Assistants (HAs) all reach out to the households approximately every three months. Certain algorithms can be integrated into their protocols to ensure everybody is tested for TB in households with TB cases.

Commodity strengthening and ensuring that the drugs are where they need to be is important. I think it is very well organised in the TB supply chain. Moreover, if we want to ensure child referrals, it is important to ensure that all paediatricians are aware of the issue and are sensitised. 

Xerses Sidhwa, Office Director, OPHNE, USAID

We have a very strong public health system in Bangladesh but we need to ensure that we are continuously strengthening it, especially the laboratory and diagnostic space. Ensuring both access and utilisation of those services is important. In addition, we need to make sure to aware the people while we expand services at the community level. In Bangladesh, one of the largest mortalities for children is pneumonia. There might be some cases of child TB and we need to think how we can improve the systems involved.

Starting conversations among communities where people talk and share their stories about TB can play a significant role. In addition, creating a multi-sectoral approach between other ministries can help. For instance, adding examples of TB diagnosis, fighting stigma can be included in national textbooks.

Dr Ahmadul Hasan Khan, Monitoring & Evaluation Expert, National TB Control Programme

If we want to attain the SDGs by 2030, there is no alternative to proper case detection and patient identification. To increase the identification of new patients, we should ensure diagnostic facilities as well as door-to-door access. To achieve this, we are currently designing our action plans keeping the GeneXpert machine in consideration.

Chayanika Chowdhury, Writer and Director (Film and Drama)

A few years back, we had a young female house help who was diagnosed with TB and Hepatitis-B. My family and I ensured that she receive full treatment and after a year, she finally recovered. My message, therefore, is that we should not neglect people if they have TB as they have hope for survival if proper treatment is given. Also, we should be aware that anyone, regardless of his/her social status, can have TB.

Sumaiya Shimu, Actress and Founder & Chairman, Better Future Communication

Disseminate proper information to those who need it the most to achieve the effectiveness of TB control. I agree that media personalities can have a profound effect on mass people by raising awareness because people tend to remember it more.

Prominent social media influencers can also raise awareness on the issue in a comparatively short time span and expense. For example, countries in Africa raise awareness by bringing in influential people or celebrities from different arenas to raise awareness on TB. Celebrities can also join fundraising initiatives for TB.

Dr Asif Mujtaba Mahmud, Consultant, Respiratory Medicine, Asgar Ali Hospital

Patients should be diagnosed early, to break the chain of TB transmission. If we ensure the proper utilisation of and access to GeneXpert machines, we can diagnose a patient early, in case of both TB and drug-resistant TB.

Secondly, we should have a social movement. For example, we can ask celebrities to disseminate simple information such as not spitting anywhere and everywhere. Thirdly, compliance with treatment has to be ensured; patients must complete their full course of medication. Otherwise, there is a chance of developing multi-drug/extensive drug resistant TB.

Finally, latent TB infection (LTBI) cases need to be addressed. NTP's initiatives regarding controlling LTBI need to be widespread.

Dr M A Hamid Salim, Global Fund/MDR-TB Advisor, National Tuberculosis Control Programme (NTP) Bangladesh

292,000 TB cases have been detected in 2019. To detect this number of TB cases, we need to conduct a large number of Presumptive TB tests. We are being able to test only four to five lakh cases with GeneXpert machines. Microscopic machines cannot accurately detect TB, leaving many undetected patients, which is a major problem.

Currently, we have around 228 functional GeneXpert machines and we expect this number to increase to around 400 by the end of this year.

Munmun Ahmed, Dance Artist and Actress

Celebrities are committed to be engaged for social causes. 

Sometimes, even after consulting doctors, ailments are not properly diagnosed. My own daughter faced such circumstances both at home and abroad.

Dr Mya Sapal Ngon, Medical Officer-Communicable Diseases Surveillance, World Health Organization Bangladesh

W recently worked with NTP to scale up preventive TB treatment. We are also planning to work on a multi-accountable framework in collaboration with NTP. We also hope that under the framework we can bring in all the partners and identify the responsibilities and functions and thus work together to accelerate the national response and quality services.

Dr Sabera Sultana, National Professional Officer-Neglected Tropical Diseases and Hepatitis, World Health Organization Bangladesh

NTP has a very good national strategic plan and now they are revising it in the context of health and social intervention. To end the TB epidemic in Bangladesh, we need to strengthen the health and social sector by achieving universal health coverage and social protection, which are also included in the SDGs.

Prof Dr Md Shahedur Rahman Khan, Director, NIDCH

As a clinician, I think undetected cases are a burden for us. Typically, before visiting a doctor, a patient already spreads the infection among others. Therefore, when we get a patient, we should visit the place they live in to detect those at risk of acquiring TB, be it active cases or latent cases. We can then treat them all and bring them under accountability.

If we can bring the inaccessible places such as the hilly areas under our coverage, TB cases will not be missed. We need to engage everyone, including celebrities in the primary healthcare networks, family planning networks, immunisation vaccination networks in Bangladesh. In that way, it will be possible to combat TB successfully.

M A Faiz, Professor-Medicine, Sir Salimullah Medical College and Former Director, DGHS

If we cannot detect resistant TB, it will continue to spread. Though the rate of resistant TB is very low in our country, it will still spread since their detection rate and treatment success are low. Therefore, we need to ensure quality care and proper patient identification.

According to TB surveys in Bangladesh, TB significantly affects elderly people. Since our life expectancy is now high in the South Asia region, we have to take steps to ensure proper detection and cure among these elderly people. Treatment for these people is difficult as they have other diseases besides TB. 

TB data need to be of adequate quality. To achieve this, we need economic resources besides human resources. Without economic resources, our funding gap will not be filled and thus may hamper the work of NTP. Government's limited budget alone cannot help in this regard.

Dr Md Akramul Islam, Director-Communicable Diseases and WASH, BRAC

We should increase the visibility of TB programmes nationally, covering all areas including villages, remote areas, etc., to increase public awareness and political attention. The development partners can help in this regard. To make a case for investment and attract more resources, we need more ambassadors, communication campaigns, fact sheets, studies, etc.

Investment is required in qualified diagnostic test kits for diagnostic facilities provided by the Government and the donors to achieve universal access to TB care. The Government is providing quality drugs for free and I would encourage everyone to take those instead of buying them from high-end medicine shops.

Dr Iqbal Arslan, Professor, Biochemistry and Molecular Biology and Former Dean, BSMMU

According to the required manpower distribution to achieve the SDGs that is prescribed by WHO, 23 total health officials are needed per 10,000 people. The required ratio is 1:3:5, which means three nurses and five supporting staff members are needed against each doctor. At present, the ratio of doctors to nurses in Bangladesh is 1:<0.8, which means there is not even one nurse against every doctor in the country. There has been a jump in the number of lab instruments, such as the GeneXpert machine, but subsequent supply of reagents or devices does not exist.

Prof Dr Md Shamiul Islam, Director, MBDC and Line Director TB-Lep and ASP, Directorate General of Health Services

Our new challenge is providing preventive treatment to adults, HIV-infected people, and to the vulnerable population. If these people are not treated, we will not be able to reduce the incidence rate. To reduce the treatment time to three months from six months, we mix a new drug called Rifapentine with Isoniazid (INH). We are testing this and have found good adherence.

In the next three years, we plan to provide GeneXpert machines at all upazila levels. However, keeping these machines functional is very costly. We are receiving a lot of support from the Government in this regard but a gap remains.

Comparatively, our TB programme success rate and detection rate are higher in villages. The treatment rate of female TB patients is also higher in rural areas. This is because they are not affected by the stigma surrounding TB.