Reduced time to MDR TB treatment in Bangladesh aids in fight to stop TB

Identifying people with tuberculosis (TB) is only a small piece of the puzzle experts are piecing together to stop the spread of the disease. Rapid treatment initiation for multidrug-resistant TB (MDR-TB) patients is critical for infection control, better management of the disease, and improved treatment outcome. For patients in Bangladesh, the time between diagnosis and treatment could last months—during which time the infection could spread to family members and others—due to long in-hospital treatment times and a lack of beds, which prohibits timely admission of newly diagnosed patients. To close the gap between diagnosis and treatment, the TB CARE II project introduced new policies and programmatic interventions that proved effective to recycle the limited number of MDR-TB beds in treatment initiating facilities more frequently, creating opportunities to quadruple the treatment capacity while significantly reducing the treatment delay.

TB CARE II, which started in 2011, works with the National TB Control Program (NTP) in Bangladesh and respective district and upazila (sub-district) level health officials to introduce policies and improvements to enhance national capacity for MDR-TB treatment. The introduction of community-based, programmatic management of MDR-TB (cPMDT) is a landmark strategy in this direction. This model has been gradually expanded to the entire country to allow patients to continue and complete their treatment at home. A directly observed treatment (DOT) provider is assigned to administer the anti-TB drugs under the supervision of an upazila based outpatient MDR-TB management team. The patients are transferred to the community immediately after sputum conversion, which usually takes less than two months. The approach has been effective in enrolling and initiating treatment to more new patients at hospitals, as beds become available more quickly through the rapid transfer of patients from the hospital to the community.

The strategy has been complemented with policy changes in treatment provision and expanding the capacity for in-patient management of patients. These efforts have led to reducing the in-patient treatment duration at facilities from an average of six to eight months to less than two. This change itself has enabled NTP to use a single MDR-TB hospital bed for treatment of four patients in a year, instead of one in the past. Apart from expanding the treatment capacity within the existing two hospitals, management of MDR-TB has been decentralized for the first time and more than 90 beds are available through four new district chest disease hospitals. Service providers from the treatment-initiating hospitals have been trained in the programmatic management of MDR-TB, in accordance with national guidelines. Technical support has been provided to continually update records of diagnosed MDR-TB patients and link with the hospitals across the country in order to register patients for treatment as beds become available.

Introduction of the cPMDT model drives a significant reduction in the number of days patients wait for treatment initiation after TB diagnosis

Introduction of the cPMDT model drives a significant reduction in the number of days
patients wait for treatment initiation after TB diagnosis

The impact of these initiatives has been striking. Treatment initiation delay was sharply reduced in 2012 when the cPMDT model was introduced by the project. At the national level, the median number of days between diagnosis and treatment initiation for all patients on cPMDT has come down, from 69 days in 2011 to six days in 2014. For patients at Chittagong Chest Disease Hospital and the National Institute of Diseases of the Chest and Hospital, the two largest providers of MDR-TB services, treatment initiation delay dropped from 84 to only three days, and from 158 days to 12 days, respectively. The number of patients on the wait list for treatment initiation has also rapidly declined, due to the increased availability of beds at hospitals.  (Note that these data only include patients transferred to community-based treatment implemented with project support.)

The expansion of hospital capacity for inpatient management of DR TB patients and transfer of patients to cPMDT, usually within two months after initiation of treatment, have enabled Bangladesh's National TB Control Program to significantly increase the enrollment of patients in treatment.

Patient initiated treatment at a new district hospital.
Patient initiated treatment at a new district hospital.
Date 
March 23, 2015
Authors 
Dr. Paul Daru, Team Leader, TB CARE II Bangladesh; Dr. Manzur-ul-Alam, Program Specialist, MDR-TB, TB CARE II Bangladesh; Krishnapada Chakraborty, Senior Technical Advisor, URC
Regions/ Countries