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Tuberculosis in Bangladesh

Third world countries are currently struggling with many dangerous diseases, one of

which is Tuberculosis. In response to Bangladesh having the sixth highest prevalence of

Tuberculosis cases and mortalities, the United States Agency for International Development

(USAID) has created the Care II Project designed to give patients more comfortable, efficient

treatment.1 Currently less than half of the patients effected by Tuberculosis in Bangladesh are

being diagnosed.1 This leads to the rapid and widespread of the Tuberculosis bacteria.2

Bangladesh is considered an optimal host for this bacteria to thrive because it presents an

abundance of risk factors, including but not limited to, massive poverty, extensive overcrowding

combined with a transient population, malnutrition, and religious constraint.2,3 For these reasons,

Bangladesh has become one of the few nations that Tuberculosis provenance has actually

increased whereas everywhere else they are learning to manage the spread of this dangerous

bacteria. Unless Bangladesh takes action now to increase knowledge and create a better system

of detection this endemic will only continue to grow.

The current action Bangladesh is taking to decrease the prevalence of tuberculosis is the

bare minimum required by the Center for Disease Control (CDC) and World Health

Organization (WHO). In May of 2014 WHO, in conjunction with several other national health

organizations, put out their recommendation and goal as to how the global community, are going

to eliminate Tuberculosis.4 The agreed upon hope in that by 2035 Tuberculosis will be

eliminated from all communities, and this elimination should be of top priority.4 The pillars of

how the global nation will make this happen are as follows: to provide patient-centered care, to

provide strong political support, and to increase research efforts.4 While all three of these broad

steps are a necessary start, they must be taken to the next level and put into action around the
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world. There are significant barriers to this approach. There are no specifics as to how each step

should be accomplished and each requires funding and nationwide participation in order to

achieve real success. While these efforts have currently been implemented in Bangladesh, they

are not successful because of the cultural barriers that are in place.

Tuberculosis is a high priority for health organizations because it is a highly

communicable disease that is hard to diagnose and treat.2 Tuberculosis is an airborne bacterial

infection that effects the patients lungs, leading to coughing, fatigue, fever, night sweats and

more.2 A large number of the Tuberculosis cases include patients with latent Tuberculosis. Latent

tuberculosis is when an individual does not show symptoms of the disease however, they still

carry the pathogen and can transmit it to others.2 Latent Tuberculosis is particularly scary

because while it does not affect the patient directly it is very hard to diagnose, meanwhile the

patient is still able to transmit the disease to those close to them. The current treatment for

Tuberculosis is six months of taking INH or RIF pills, that can be quite harmful to the patient.2, 5

For this reason, many people in the past have prematurely stopped treatment once the symptoms

subside. One of the major reasons for the increased prevalence of this disease is that it has such a

long treatment period, which becomes a burden to families. This has caused the disease to mutate

developing into multi-drug resistance (MDR) Tuberculosis.6 MDR Tuberculosis is a form of

Tuberculosis that has become resistant to the drugs that are usually used to treat Tuberculosis.6

This has become especially tricky because the treatment time with this strain is four times longer

than the regular Tuberculosis and the medications used cause several dangerous side effects.2 To

this day there is not a safe way to treat patients diagnosed with MDR tuberculosis.

Bangladesh is currently working off the CARE II plan presented by the USIAD which

has led to the implementation of several preventative measures.1 Bangladesh recently put in
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place the directly overserved treatment (DOT) program.7, 2 This dictates that high risk patients

are observed taking the tuberculosis treatment, which helps to ensure that patients actually

completely their treatment plan. Bangladesh has also been in the process of building

Tuberculosis treatment centers across the nation to provide easier access to treatment.5 These

centers are designed to have the technology to accurately diagnose Tuberculosis at all stages.

There have been initiatives implemented that are designed to help better train health care

professions in identifying as well as diagnosing Tuberculosis.1,8 These programs, while targeted

for people working in the health care system, are also open to community members who are

looking to support the cause.1 Through the use of some social media, in conjunction with word of

mouth, there has been as attempt to distribute accurate information about Tuberculosis to the

peoples across Bandladesh.8 As accurate knowledge is spread to a wide range of people, it allows

for a better understanding of each persons individual risk factors. Patients are also more likely to

seek out treatment for themselves, or their family, if they are better informed about the dangers

of this disease. The spread of accurate knowledge is a primary factor in the ability to diagnose

patients and ensure compliance with the full treatment regimen.

Bangladesh has made some great initial steps in combating Tuberculosis however, more

must be done to make a bigger impact if there is ever hope to make Bangladesh a safe place to

live. There are currently a lot of challenges that must be overcome before a highly noticeable

difference in Bangladesh can be made. A lot of these challenges stem from the culture in

Bangladesh as well as the environment in which they live in. Bangladesh has been plagued with

overcrowding.9,10,11 In the 1970s the primary religion in Bangladesh was Islam, which

encouraged procreation, producing large family sizes.10 While fewer people practice this faith,

the result of high birth rates is still effecting the country today. The average family size has
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decreased from 5 children to about 2.5.10 Even though the family size has decreased the

overcrowding is still a factor and makes Bangladesh an ideal environment for the spread of

Tuberculosis. Since this is an airborne bacterium, the closer quarters people are forced to reside,

the easier it is for entire families to become infected. The overcrowding allows for several people

to become infected at once. While there is no easy way to eliminate this problem, encouraging

people to closely watch their family members and to implement some form of isolation once one

member is effected may be able to help decrease the likelihood that an entire family would

become infected with the disease.

Poverty is another factor that has allowed the Tuberculosis bacteria to thrive in

Bangledesh.11, 9 According to Paediatrica Indonesiana approximately 4 out of 10 people make

less than a dollar a day, meaning that they are well below the poverty line.13 It is common for

people to live in a slum environment and for all family members to be constantly working.11, 3

Since the treatment for Tuberculosis is so long, 6 months, and patients are required to

consistently visit a clinic to be monitored and to pick up their medication. This becomes a burden

on the family.7 Due to the primary socio-economic status being so low, it is crucial that even

individuals diagnosed with Tuberculosis are back at home as soon as possible so that they can

work. Clinics are not available in every single village, which means that travel to receive a

diagnosis or treatment can be a lofty trip.7 Outside of time wasted from going to and from the

clinics, the treatment and medication itself is expensive, especially if any form of hospitalization

is required.7 Some clinics are able to perform the diagnostic testing and give medication at a cost

only to the government itself, however these clinics may be even further away from the patients

primary location.7, 11 The primary cost to patients comes from a loss of work for the patient, as

well as their care provider. This only encourages patients to stop treatment early so they can
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return to work, or to not seek treatment at all until the bacteria has already mutated and is unable

to avoid. This is a huge contention because unless people are willing to come to clinics at the

first sign of the disease, they will only spread the bacteria to others causing the epidemic to

spread quickly. It is currently financially unwise for patients to seek treatment; this is a problem

that needs to change. Some ideas are to find a way to shorten treatment length, give individuals a

financial incentive to seek treatment, and reduce travel time for everyone, specifically targeting

rural areas.

Another challenge for this area is the significant transiency of the population.9 This leads

to a plethora of road blocks including an inability to track patients and their treatment, a

difficultly spreading accurate knowledge that will reach everyone, and that transiency is an

effective way for the Tuberculosis bacteria to travel from one community to the next swiftly.

Since patients are constantly moving, it is nearly impossible for clinics to manage the individuals

living in their community as they are ever changing. Even if clinics were to attempt to test

everyone there is no way of monitoring when families move or arrive.8 This causes a lot of

incomplete data collection, which creates an incomplete and inaccurate picture of how

detrimental Tuberculosis is on this nation.4 One way that Bangladesh is attempting to combat

Tuberculosis is ensuring that everyone how accurate information. In the study done by the

Journal of Health, Population, and Nutrition, it shows that current citizens of Bangladesh have

an insufficient knowledge of how to identify Tuberculosis, seek treatment, and what the risk

factors are.12 This lack of knowledge is caused by the transient mentality. People are moving all

other the country making it difficult to spread knowledge, without it getting construed through

misunderstanding. Lastly this transient nature allows the bacterium to spread far and wide. If one

location is infected and someone moves from that area to another, they are most likely carrying
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the bacteria with them and will infect this new population. As people move around they are

giving the Tuberculosis bacteria an ideal way to affect the masses easily. These challenges are

hard to overcome and it would require a behavioral change that is extremely hard to achieve. In

the meantime, however, if the government began using country wide forms of communication to

spread information it would decrease these misconceptions and allow for the same information to

spread everywhere.

Bangladesh is a country that has high levels of malnutrition, primarily due to the large

number of impoverished individuals and immense overcrowding. Malnutrition leads to a

decrease in the bodys immune system.13 It is very common for Tuberculosis to begin in the

latent stage, but the weakening of the immune system from malnutrition can cause it to turn

active. As more and more children are living in these slum locations, unable to get adequate

food, their risk obtaining Tuberculosis greatly increases. While it may seem contradictory, in the

last few years there has been an increase in agricultural distribution, increasing the economy in

Bangladesh, the malnutrition status did not change.13 This increase of wealth in Bangladesh has

exaggerated the problem by creating an even larger wealth gap across the nation.13 When

individuals are unable to receive adequate nutrition their bodies must distribute the limited

energy they have into performing necessary function, greatly decreasing the amount of energy

left for the immune system. This decrease in immunity does not only contribute to the advancing

cases of Tuberculosis but every chronic disease, including HIV. Which has been recently

connected to the advancement of the Tuberculosis endemic.2 When an individual has HIV it

requires the full use of the immune system to fight this nasty disease. This leads to an opening

for Tuberculosis to join in attacking the body. The combination of these two diseases working

together is becoming more popular across the nation, and is increasing mortality rates.2 When
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HIV and Tuberculosis are co-infecting a patient it also makes the Tuberculosis treatment more

dangerous as the side effects are magnified.2 Treatment must therefore be modified creating a

greater risk for a relapse, usually causing the development of MDR Tuberculosis.2

When attempting to tackle the problem of Tuberculosis in Bangladesh there are many

cultural challenges that must be worked around. This can be an overwhelming endeavor,

particularly when it may seem that there are more pressing matters that must be eradicated first.

However, as steps are taken to eliminate this Tuberculosis it will require the country as a whole

to make large changes that will in turn decrease the prevalence of other chronic diseases.

Bangladesh has already taken several promising step to attempt to decrease the cases of

Tuberculosis by following all recommended pans given by the USAID, WHO, and the CDC.

While this is a start, the fact that Bangladesh is still one of the few nations that there is an

increasing number of Tuberculosis cases, it is essential that they need to take these programs a

step further. Since Tuberculosis is highly contagious the first step is going to be to create a better

system for identifying every case at its initial onset. The next step will be to increase the

knowledge the population has for this disease in order to help people avoid future risk factors.

Step three will be to decrease the economic burden Tuberculosis has on families in order to

create greater incentives to receive treatment. The last step will be to increase research and

continue prevention measures, even when the disease burden has decreased.

There has been a significant amount of research in Canada about the screening Refugees

for Tuberculosis when they enter the country.5 Canada has been dealing with a large number of

refugees coming to their counties from high risk locations. In response they created a system in

which all legal immigrants are required to receive all recommended vaccines and be tested for

Tuberculosis before they are approved to live in Canada. This project has been successful in
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allowing people to take refuge as well as keeping the current citizens safe from disease. A

similar model could be translated to work in Bangladesh. When tackling Tuberculosis, it is

essential that everyone is teste to ensure there is accurate data. Since there is currently no way for

clinics to regulate who does or does not get tested, it is up to each subgroup community to hold

each other accountable. There are many women in Bangladesh that are looking for work who

could be trained to identify tuberculosis. Once clinics were created to teach at least one women

in every two-mile radius, they could go out and test each individual in their home. These women

would be trained as nurses, with the knowledge necessary to give patients accurate information

on how to receive treatment for Tuberculosis. Once these women were in place it would then

become a community effort to keep their neighborhood safe from future outbreaks. The small

challenge of the transient population would also be fixed, because similarly to the refugees, once

a family enters a new community they can be immediately tested.5 This style of immediate

testing has been successful in Canada by almost eliminating all cases of Tuberculosis. It could

also be combined with eliminating other chronic diseases by administering vaccines in

conjunction with testing for Tuberculosis.5 Another benefit of this type of community

involvement is that these women would be able to send the data they collected, as to the number

of individuals effected, to the closest clinic allowing more accurate knowledge as to the size and

distribution of the disease. The size of Bangladesh and the unwillingness of people to go out and

get tested themselves is a challenge that is solved using this approach. This program will increase

the number of available jobs for women, increasing their familys income and therefore

decreasing the number of families below the poverty line. This would therefore benefit the

countries overall economy. People do not have to leave their homes to ensure their family is safe,

and this is a great way to empower women, giving them a clear purpose within the community.
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The next step to eradication would be to increase the publics knowledge about this

disease. There was a study done by African Health Sciences which indicated that the citizens of

Bangladesh have an only an elementary knowledge of Tuberculosis, especially lacking in

knowing the risk factors of the disease.11,12 This is a problem because families need to be able to

avoid risk factors and identify when a family member is infected, so that entire families do not

develop and spread the disease.11,12 Once community nurses are hired it would be essential that

they are responsible for going home to home, ensuring that every family has at least one member

that is highly knowledgeable on the subject. This would create a community surveillance

system.10 If each person could identify when a neighbor is infected by Tuberculosis and insist

they reach out for treatment, it would promote a positive, healthy environment. Each clinic does

not have the capacity to watch every individual within their community. Promoting community

involvement through increased knowledge and self-surveillance will encourage people to seek

and complete treatment.10 The overcrowding issue would become an advantage because it would

be harder for people could hide from receiving treatment. Another underused platform is that of

television and radio.3 If the government was able to create countrywide ads that played

nationwide twice a day, both on the television and radio, accurate information would get out to

the public rapidly.3 This method would also ensure that all citizen would have the same

knowledge about this disease as well as which risk factors to avoid. This would alleviate the

problem of transient families, because it would be a country wide distribution. It would no longer

matter what community you were in or moving to, everyone would have the same accurate

information.

When attempting to eliminate chronic disease, the economic burden to the families

infected is often overlooked.7 The number one reason people withhold or stop treatment is
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because of the economic challenges.7 The medication is expensive, the treatment period is long,

and it is far to travel to the closest clinic.7 Since most clinics at this time are giving free or

reduced costs of medication, leading to the next step of solving the problem of travel and loss of

labor costs. In step one, the training of women in each community would be an ideal method to

solve this problem. People could be treated in their home. This would allow families to not loose

working hands, especially for a long treatment of six months. The nurses could ensure that each

patient completed the entire treatment regimen by going to each house and administering

treatment. Ensuring all treatment was completed fully would help reduce the cases of MDR

Tuberculosis, which would be a huge assistance to the safety of the country. Training and paying

community nurses would be a costly endeavor, however a necessary one that would bring back a

return to the government by saving on hospitalization costs. It would also be helpful to switch

from INH to RIF pills. The treatment is the same length, but the RIF pills are cheaper and have

shown reduced side effects.8 While there will always be a burden associated with any disease

diagnosis, these steps will decrease that cost to families and overall ensure the well-being on

every community.

Lastly all changes must continue, even once the prevalence of this disease has decreased.

Since Tuberculosis is highly contagious, any decrease in the education, prevention and diagnosis

could easily cause another outbreak to occur. Continued research in the causes, treatment and

prevention of Tuberculosis is vital to the irradiation of the disease. The treatment is very long

and it is still difficult to detect all cases of tuberculosis, especially the ones that are inactive.8 A

vaccine for tuberculosis would also significantly change the face of this disease and the effect it

has on populations around the world. A vaccine would allow the public health community to be

proactive about eliminating this disease rather than reactive as they are now.
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There are three key limitations for the proposed initiative, personal training and money.

This program requires a lot of women in need of work, would like to pursue a career in nursing

and are willing and able to be trained. If there are not enough women in each community to

commit themselves to ensuring the elimination of tuberculosis within their community, the

initiative will not be successful. If the government made decreasing the prevalence of

Tuberculosis their primary priority it would encourage women to stand up and help. The training

of these women would also be expensive. The government would need to find and pay

knowledgeable staff who could train the woman, who in turn would need to be paid for their

services. Bangladesh, while their economy is growing, they would not alone have enough to

supply all of the necessary funds. While they would be a good candidate for outside funding

from the CDC, WHO, or other outside investors there is no guarantee they would be able to

receive the necessary assistance. The final limitation is facilitating the training of these women.

It is essential that they have up to date knowledge on Tuberculosis. The locations for these

training to occur must be widespread so that every community has easy access, however they

must each teach the same information. Ensuring that these trainings are successful and

convenient is a challenge that can be solved by providing financial incentives to attend these

trainings including covering travel expenses to the training locations. Without the fulfillment of

these three limitations it will be impossible to find success with this proposal.

Bangladesh in one of the few countries where the prevalence rates of tuberculosis are

going up.1 Unless the country as a whole is willing to put their personal agendas behind and

work toward the common goal of treating all tuberculosis cases immediately, the disease will

continue to mutate becoming more deadly, causing more destruction. Taking steps to train and

educate the people of Bangladesh will not come cheap, it almost always leads to a financial
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return and the satisfaction of saving a community. God is not prejudice when it comes to who is

effected by disease.14 It is therefore the global communitys responsibility to assist our neighbors

in their treatment and recovery in any way they can, on a global and local scale.
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References:

1. TB CARE II project overview. TB CARE II project overview. 2013.


http://tbcare2.org/sites/tbcare2.org/files/tb care ii_bangladesh_projectoverview2013.pdf.
Accessed September 14, 2016.

2. Dheda K, Barry C, Maarens G. Tuberculosis. The Lancet. 2016;387:1211-1226.


http://dx.doi.org/10.1016/ s0140-6736(15)00151-8. Accessed September 14, 2016.

3. Bam K, Bhatt L, Thapa R, Dossajee H, Angdembe M. Illness perception of tuberculosis (TB)


and health seeking practice among urban slum residents of Bangladesh: a qualitative study.
BMC Research Notes BMC Res Notes. 2014;7(1):572. doi:10.1186/1756-0500-7-572.

4. Uplekar M, Weil D, Lonnroth K, et al. WHO's new End TB Strategy. The Lancet.
2015;385(9979):1799-1801. doi:10.1016/s0140-6736(15)60570-0.

5. Rennert-May E, Hansen E, Zadeh T, Krinke V, Houston S, Cooper R. A Step toward


Tuberculosis Elimination in a Low-Incidence Country: Successful Diagnosis and Treatment
of Latent Tuberculosis Infection in a Refugee Clinic. Canadian Respiratory Journal.
2016;2016:1-6. doi:10.1155/2016/7980869.

6. Rifat M, Milton AH, Hall J, et al. Development of Multidrug Resistant Tuberculosis in


Bangladesh: A Case-Control Study on Risk Factors. PLoS ONE. 2014;9(8).
doi:10.1371/journal.pone.0105214.

7. Gospodarevskaya E, Tulloch O, Bunga C, et al. Patient costs during tuberculosis treatment in


Bangladesh and Tanzania: the potential of shorter regimens. int j tuberc lung dis The
International Journal of Tuberculosis and Lung Disease. 2014;18(7):810-817.
doi:10.5588/ijtld.13.0391.

8. Lnnroth K, Castro KG, Chakaya JM, et al. Tuberculosis control and elimination 201050:
cure, care, and social development. The Lancet. 2010;375(9728):1814-1829.
doi:10.1016/s0140-6736(10)60483-7.

9. Waheduzzaman W, Alam Q. Democratic Culture and Participatory Local Governance in


Bangladesh. Local Government Studies. 2014;41(2):260-279.
doi:10.1080/03003930.2014.901217.

10. Levine R. Case Studies in Global Health Millions Saved. Mississauga, Canda: Jones and
Bartlett Learning; 2007.

11. Mondal M, Nazrul H, Chowdhury M, Howard J. Socio-demographic factors affecting


knowledge level of Tuberculosis patients in Rajshahi City, Bangladesh. African Health
Sciences Afr H Sci. 2015;14(4):855-865. doi:10.4314/ahs.v14i4.13.
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12. Hossain, S., Zaman, K., Quaiyum, A., Banu, S., Husain, A., Islam, A., Leth, F. V. (2015).
Factors associated with poor knowledge among adults on tuberculosis in Bangladesh; Results
for a nationwide survey. J Health Popul Nutr Journal of Health, Population and Nutrition.
34(1). doi:10.1186/s41043-015-0002-4.

13. Ahmmed M. Impact of wealth inequality on child nutrition in Bangladesh. PI Paediatrica


Indonesiana. 2013;53(6):299-304. doi:10.14238/pi52.6.2013.299-304

14. Holy Bible: New Living Translation. Wheaton, IL: Tyndale House Publishers; 1996.

15. Merson MH, Black RE, Mills AJ. Global Health: Diseases, Programs, Systems, and
Policies. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2012.

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