Rising trend of multi-drug resistant TB (MDR-TB) has emerged as major threat to tuberculosis (TB) control programme in Bangladesh. Experts identified inappropriate and irregular treatment beyond programmatic control, lack of diagnostic facility and treatment of existing MDR cases as the contributor of rising number of MDR-TB patients.
According to global TB control report 2008, WHO estimated that the percentage of MDR-TB for new cases is 3.6 and for previously treated cases is 19 in Bangladesh.
TB is usually treated with a course of four standard (first-line) anti-TB drugs. Multidrug-resistant TB (MDR TB) is resistant to these drugs (or at least two of the best anti-TB drugs, Isoniazid and Rifampicin). If these drugs are misused or mismanaged, multi-drug-resistant TB (MDR-TB) can develop.
MDR-TB takes longer to treat and can only be cured with second-line drugs, which are more expensive and have more side effects. Another kind of more dangerous and almost untreatable strain of TB is termed as extensively drug-resistant TB (XDR-TB) that can also develop when these second-line drugs are misused or mismanaged and therefore it becomes resistant to all first and second-line drugs. It might be devastating for the country as the treatment options are seriously limited and the risk of death is extremely high.
Statistics show that 300,000 people in Bangladesh fall ill from TB in a year and more than seventy thousand die from it. World Health Organisation (WHO) ranked Bangladesh sixth among the world’s 22 high-burden TB countries. The WHO estimates that nearly 500,000 people a year become infected with drug-resistant TB. But the exact number of people affected is uncertain due to the lack of capacity to diagnose it accurately.
Till date, maximum emphasis is given on non-drug resistance TB and MDR-TB remains in the back seat. According to the experts, it is the high time to focus on MDR-TB.
Lack of sufficient effective programmes and low coverage of services play an important role in the growth of MDR-TB. The Damien Foundation is one of the very few organisations who are currently working to control and management of MDR TB. It has been working since 1997 and currently covering their services to 29 districts. And the government in collaboration with Green Light Committee of WHO have just started DOTS-plusstrategy to combat MDR-TB. But these services are limited to certain areas. So majority people throughout the country have not the access to proper diagnosis and treatment.
All the programmes running currently for MDR-TB have only covered treatment of about 600 patients out of total 10000 patients. Among the huge remaining MDR-TB patients most of them are maltreated and several remain untreated. This indirectly contributed to develop XDR. If timely actions are not taken to identify and treat these MDR cases its spread can not be controlled, experts warned.
Dr Md Abdul Hamid Salim, Country Director and Medical Advisor of Damien Foundation expressed his deep concern regarding MDR-TB. He pointed out that inadequate treatment and malpractice in the treatment of TB contribute majority of MDR TB cases. He said, “Mismanagement of ordinary TB gives rise to MDR –TB and further mismanagement of MDR-TB will give rise to more dangerous XDR-TB.”
He mentioned that in private practice, many doctors prescribe an additional 2nd line drug (Quinolone group) along with specific standard TB regimen for better outcome. But it is strongly prohibited as it can give rise to XDR TB. He urged that sound implementation of DOTS strategy, detection of existing MDR TB cases and rational use of Quinolones are imperative in preventing the development of MDR TB and XDR-TB. He also added that patients with suspected TB should not readily be treated by antibiotic Quinolone that is a 2nd line drug for TB.
Dr Erwin Cooreman, Medical officer — TB, WHO Bangladesh has shared the WHO’s plan of action. He stated that lack of diagnostic facility and expensive long term treatment are key obstacles to tackle MDR-TB. He said that quality must be assured. Control of drug resistance TB will rely on quality assured and internationally recommended treatment regimens administered under strict supervision as part of the Directly Observed Therapy Short course Plus (DOTS-Plus) programme. He warn that the existence of MDR-TB is a serious and emerging public health threat and its superior XDR-TB can also be more fatal for the country.
TB here in Bangladesh is closely related to financial burden and social stigma. More than three quarters of all TB cases are among people 15–54 years old – those in their prime working years. If the only earning member is affected, the entire family suffers huge economic crisis and their sufferings knows no bound. The disease is therefore a major cause of poverty for affected individuals and their families. Ironically, MDR-TB patients need to be admitted into hospitals for as long as 5-6 months for proper supervised treatment and management of side effects.
Moreover, expensive drugs for MDR-TB are not produced in Bangladesh. Importing of drugs adds additional financial burden.
In many parts of the country, TB carries a stigma that has to be overcome. Patients may be afraid they will lose employment and income as a result of the disease; they may not realise the threat they pose in spreading disease to the rest of the community; and they may see the insistence on their taking tablets and injections as an infringement of rights.
Dr Asif Mujtaba Mahmud, Associate Professor of National Institute of Diseases and Chest Hospital (NIDCH) has identified lack of technical and financial support contributes in rising trend of MDR-TB. He informed that we have only 3 internationally recognised labs for culture sensitivity testing for MDR-TB. These need to be expanded. “Social rehabilitation can reduce the financial burden.” he noted.
Fight against drug resistance TB is very challenging in a country like Bangladesh. Without cumulative effort and joint movement it is not possible. Experts urge all citizens to come forward and participate pro actively to combat TB effectively and to ensure that every person with TB has access to accurate diagnosis, effective treatment and cure and to stop the transmission of TB.
Source: The Daily Star, February 21, 2009