ICDDR, B shows the way of detecting ‘missing’ TB cases in Bangladesh

As Bangladesh’s health system cannot detect and notify about a third of the total TB cases, the ICDDR, B has shown the way with its unique public-private mix or PPM approach to diagnosing undetected cases.

The Dhaka-based health research centre took an innovative approach and set up TB screening sites in 2013 with state-of-the-art facilities targeting possible cases for testing from the physicians working in the private sector.

Those doctors including the evening practitioners are unable to report tuberculosis cases they diagnose and treat, as there is no available notification tool in Bangladesh. The private sector also lacks quality assured and sensitive TB diagnostics.

TB remain undiagnosed or unreported means many will die or continue to be sick and transmit the disease or, if treated with improper drugs, contribute to the growing menace of drug resistance.

This year’s world TB day observed on Saturday was themed on “Wanted: Leaders for a TB-free world”.

The focus of the day was on building commitment to end TB, not only at the political level with heads of state and ministers of health but all levels from leaders to people affected with TB, civil society advocates, health workers, doctors or nurses, NGOs and other partners.

TB being a ‘notifiable’ disease, all private doctors, caregivers and clinics treating TB patients are supposed to report each case to the government through the nearest government health officers.

The aim is to ensure proper diagnosis, case management, transmission reduction, and fighting the emergence of drug resistance in Bangladesh, where an estimated 33 percent of the total cases remained missing in 2017.

Diagnosing and treating TB patients are expensive, and that’s why it is government and donor-supported initiative to stop the infectious disease transmission by 2030. The Bangladesh government also distributes expensive drugs free with the help of the Global Fund.

“Our focus was to how we can bring the private patients into the government programme. We took an innovative approach of how to ensure quality diagnosis for them and bring them under government reporting,” Sayera Banu, a senior scientist of ICDDR, B who oversees the TB programme of the research centre, told bdnews24.com.

She said they started with three screening centre in Dhaka in 2O13 and now the programme has been expanded with four more centres in Dhaka and two in Chittagong and one to be launched in April in Sylhet.

Sixty-year-old Akram Uddin was sitting at a wide, brightly lit waiting room of the Dhanmondi centre on Saturday. He told bdnews24.com that he came to test for TB with his daughter.

His daughter said a doctor at a private hospital referred her father to this centre to avail the free testing. “I know the government hospitals also test TB, but those are very crowded and not so clean as I find here,” she told bdnews24.com.

On arrival, a patient has to register and then wait for the call. First, they go to a room where a nurse takes their history. After that, they are shown a video of how to produce “effective” cough sample for testing. They cough into a container in a separate room. Then the X-ray image is taken. The whole process takes 2O minutes. The next day they come to take the report.

The centre is equipped with state-of-the-art digital X-ray systems and GeneXpert MTB/RIF systems which can diagnose both TB cases and drug resistance within a short time. There is the provision of voluntary diabetes testing.

Private providers remain engaged all the time. The government’s drug is also supplied to those who are confirmed TB. Those who test positive are counselled by health workers when they return to collect their results.

They are also referred for free treatment to a National TB Programme linked DOTS centre nearest to where they live or sent back to the referring physician for treatment in the private sector.

Since September 2013, more than 100,000 presumptive cases were tested with GeneXpert and nearly 60,000 with chest X-ray, identifying more than 13,000 TB cases.

“Following our success, the government has adopted this model in the National Strategic Plan of Bangladesh (2016-2020),” the senior scientist, Banu, said.

“Our centres have extended operational hour to till 10pm so that patients referred by the evening practitioners can test on the same day,” she said.

Dr Asif Mujtaba Mahmud, a consultant of respiratory medicine, at Asgar Ali Hospital in Gandaria, told bdnews24.com on Saturday that he also refers his patients to those centres.

“Just today I confirmed a patient TB, and I put him on drugs. He was delaying his treatment as he would not go to the government facility because he did not like the environment. When he came to me, I referred him to the ICDDR, B facility. It's totally free,” he said

“They [icddr,b] have advanced technology. The access is very easy and its all free of cost. And once a patient goes there, he or she is being notified in the government system”.

Dr Mahmud said for private practitioners like him, there is no mechanism to notify TB cases to the government. The ICDDR, B centres give them that chance.

“They can also diagnose multi-drug resistant TB early; who are then referred to the government’s chest hospital for treatment.”

“To combat TB, we need partners. Only government or private sector cannot do that. We need leadership. The success we have achieved in TB detection in Bangladesh was because of partnership.”

But the challenges remain. Last year when those ICDDR, B centres started receiving government’s funds, they had to offer everything free, changing their previous social enterprise model in which a nominal charge for X-ray was taken.

“After offering everything free, we don’t have a separate budget for buying x-ray films or paying to radiologists as there was no such allocation from the international donors. We used to manage that from the revenue we collected by the social enterprise model,” the senior scientist, Banu, said.  They are now finding options to address the challenge.