Activity 7: Infectious Disease

PI: Dr. Stephen P Luby

Communicating results of infectious disease surveillance

The Health and Science Bulletin (HSB) is a quarterly publication which communicates results of our routine infectious disease surveillance, as well as other new health research findings, to the Bangladeshi public health community in both Bangla and English.

Surveillance of Multi Drug Resistant Tuberculosis (MDR-TB) in Bangladesh

FPI: Dr. K Zaman

Bangladesh ranks as the 5th highest TB disease burden among 212 countries in 2005, having 300,000 new cases and 70,000 deaths yearly. Better understanding of the prevalence of anti tuberculosis drug resistance is one of the key elements in the control of TB. The magnitude of anti-tuberculosis drug resistance in Bangladesh is not precisely known.

The emergence of MDR-TB and its effect on epidemiology is complex and multi- faceted. Very little is known about these factors which are associated with drug resistance TB in Bangladesh. Better understanding of underlying issues that defines the emergence of drug resistance TB is of immense importance. Globally, the reporting of extreme drug resistant TB (XDR-TB) and widespread HIV prevalence has made the situation more complex. Continuation of the existing MDR surveillance is important to effectively plan for the treatment of MDR cases and implement DOTS-Plus strategy in Bangladesh. Appropriate measures to control and prevent drug resistant tuberculosis in Bangladesh to reduce mortality and transmission are warranted.

Currently multi-drug resistant (MDR) surveillance is continuing at Shyamoli TB clinic in urban Dhaka in collaboration with the National TB Control Programme (NTP).

The MDR surveillance supported by IHP is the only source of data on drug resistance patterns of tuberculosis in Bangladesh using systematic sampling techniques through established surveillance system.

Collaborating Institution:

• National TB Control Programme (NTP)

Results:

• Out of 657 isolates, resistance to one or more drugs was observed in 48.4%. Resistance to streptomycin, isoniazid, ethambutol and rifampicin was observed in 45.2%, 14.2%, 7.9% and 6.4% respectively. Multi-drug resistance was observed in 5.5%. It was significantly higher among persons who previously received tuberculosis treatment of ≥1 month (15.4% vs. 3.0%).
• We regularly provide the results to the NTP and is being published in every issues of ICDDR, B Health and Science Bulletin (HSB). Our findings have been presented in different national and international seminars and forums. The findings are also published in Scandinavian Journal of Infectious Diseases in 2005.
• We hold a dissemination seminar in ICDDR,B in collaboration with NTP and BRAC. It was attended by about 200 participants from different partners and NGOs.
• ICDDR,B in collaboration with NTP established a quality controlled laboratory meeting biological safety standards for isolation of Mycobacterium tuberculosis at Shyamoli TB clinic.

Pulmonary Tuberculosis (TB) among inmates of the largest prison in Bangladesh: magnitude of problem, multi-drug resistance and transmission

FPI: Dr. Sayera Banu

Pulmonary Tuberculosis (PTB) consumes people from within, with cough (with or without blood), fever, pallor and long relentless wasting. National Tuberculosis Control Programme (NTP) provides free treatment to patients but there is limited data available on the burden of TB. That means the policy makers do not have access to enough information to assess the resources needed and evaluate success of current treatment, service delivery or measure any actual improvement.

Usually, in developing countries prison populations have five to ten times higher prevalence rates of TB. In some occasions it is as high as 20 to 30 times. In Bangladesh, adequate data are not available to make any assessment to effect our public health policy on TB control.

In this study, ICDDR, B collaborated with NTP to determine the prevalence of pulmonary TB in the Dhaka Central Jail, the largest prison in Bangladesh. It has a capacity of about 2,600 inmates but currently accommodates nine to ten thousand inmates.

Prison population is inherently high-risk to be infected with TB in comparison to the overall population. Once inside the jail, congested accommodation drastically increases the transmission rate among the inmates and also infects those who do not have TB. In effect, people coming out of the jail are consistently bringing in TB in general population.

Currently the inmates are expected to report to the medical authority with their problems and if identified as having tuberculosis, treatment is given following current national guideline. Dhaka Central Jail has only the facility conducting AFB (Acid Fast Bacilli) microscopy test which is inadequate and is able to detect merely one-third of open TB cases.

We have proactively interviewed every possible inmate about likely TB symptoms and investigated sputum samples by AFB microscopy, culture and PCR (Polymerase Chain Reaction) at the centre facility. We were able to identify around 65% more confirmed cases and detect 15% more patients without severe symptoms. With the support of jail authority it is also ensured that TB patients are isolated and given necessary treatments.

From our study we were able to find that the population in Dhaka Central Jail has 20 times higher TB national prevalence rate. We have also been able to assess further scope of research that can provide information on how to modify the NTP programme to identify and treat TB patients in prison more accurately.

Collaborating Institutions:

• National TB Control Programme (NTP)
• Dhaka Central Jail

Results:

• Sputum samples and related clinical data of the suspected cases (cough >3 weeks) are collected from the Dhaka Central Jail. AFB microscopy, culture, PCR, antibiotic susceptibility testing and DNA fingerprinting of M. tuberculosis strains are performed.
• The prevalence rate of sputum positive pulmonary TB was 2,200/100,000 which is much higher than the national rate and 23% of all positive cases were diagnosed by culture and/or PCR after AFB microscopy failed to detect the infection. No MDR TB was found in the prison population. Active screening performed in the study has significantly increased the case detection of TB in the Dhaka Central Jail. The identified TB patients are immediately picked up by the Central Jail Hospital and are brought under treatment.

Improving Surveillance of Kala-azar in Bangladesh

FPI: Dr. Kazi Md. Asif Jamil

Visceral leishmaniasis (also known as kala azar) is a serious illness which is endemic in many districts of Bangladesh. The disease is caused by a parasite called Leishmania donovani and is transmitted by sand-fly, and affects mostly the poor people living in the endemic areas. Most patients suffering from kala azar die if they are not treated properly. In 2005, the Ministers of Health of the Government of Bangladesh, India and Nepal signed an agreement to eliminate this disease from the region and set up a target to reduce the incidence of the disease to less than 1 per 10,000 population at district and Upazilla level by the year 2015. We developed a proposal to collaborate with IEDCR, NIPSOM and DGHS to improve the surveillance of kala azar in Bangladesh which would be an important component of the Kala azar Elimination Programme of Government of Bangladesh.

In Bangladesh, most of the kala azar cases occur in Mymensingh District. Within Mymensingh District, the highest incidence has been reported from Fulbaria, followed by Trishal Upazila. ICDDR,B had conducted a study on kala azar in Fulbaria in collaboration with CDC, Atlanta, and the PI is still conducting a follow up study there. Thus we chose Trishal Upazila for kala azar surveillance study, so that new information could be obtained from this area with a high burden of the disease.

The case referral system developed by us and now being tested in Trishal has been presented recently in some meetings with the policy makers in the presence of representatives from WHO (South East Asia Region Office). Everyone highly appreciated the activity and some of the experts suggested incorporating it into Kala azar Elimination Programme of the whole region. We hope to present the findings in a wider forum of the policy makers and other stakeholders after the final evaluation of the study in December 2007.

Collaborating Institutions:

• DGHS
• IEDCR

Results:

• The findings is expected to be helpful for policy makers like WHO office of South East Asia Region and Kala azar Elimination Programme
• Village health volunteers were trained to identify suspected cases and refer them to the government health care facilities.
• Some IT facilities were introduced and this will enable health authorities to take prompt measures when needed, for instance, during an epidemic or non-response to therapy due to drug resistance, etc.