The Multi-Drug Resistant Tuberculosis Diagnosis and Treatment Cascade in Bangladesh.

Ashaque Husain,Petros Isaakidis,S M Mostofa Kamal,Karuna D Sagili,Selvakumar Subbian,Md Akramul Islam,Shayla Islam,Hemant Deepak Shewade,Sarder Tanzir Hossain

doi:10.1371/journal.pone.0129155

Abstract

ObjectivesTo determine, in areas supported by BRAC, Bangladesh i) the pre-diagnosis and pre-treatment attrition among presumptive and confirmed Multi-Drug Resistant Tuberculosis (MDR-TB) patients and ii) factors associated with attrition.MethodsThis was a retrospective cohort study involving record review. Presumptive MDR-TB patients from peripheral microscopy centres serving 60% of the total population of Bangladesh were included in the study. Attrition and turnaround time for MDR-TB diagnosis by Xpert MTB/RIF and treatment initiation were calculated between July 2012 and June 2014.ResultsOf 836 presumptive MDR-TB patients referred from 398 peripheral microscopy centres, 161 MDR-TB patients were diagnosed. The number of diagnosed MDR-TB patients was less than country estimates of MDR-TB patients (2000 cases) during the study period. Among those referred, pre-diagnosis and pre-treatment attrition was 17% and 21% respectively. Median turnaround time for MDR-TB testing, result receipt and treatment initiation was four, zero and five days respectively. Farmers (RR=2.3, p=0.01) and daily wage laborers (RR=2.1, p=0.04) had twice the risk of having pre-diagnosis attrition. Poor record-keeping and unreliable upkeep of presumptive MDR-TB patient databases were identified as challenges at the peripheral microscopy centres.ConclusionThere was a low proportion of pre-diagnosis and pre-treatment attrition in patients with presumptive and confirmed MDR-TB under programmatic conditions. However, the recording and reporting system did not detect all presumptive MDR-TB patients, highlighting the need to improve the system in order to prevent morbidity, mortality and transmission of MDR-TB in the community.

Highlights

Despite progress in the detection of Multi-Drug Resistant/Rifampicin Resistant Tuberculosis (MDR/Relative risks (RR)-TB) cases, major diagnostic gaps remain: 55% of reported TB patients estimated to have MDR-TB were not detected in 2013 [1].Timely identification of MDR-TB cases and prompt initiation of treatment are crucial to prevent the transmission of disease and reduce related high morbidity and mortality [2]
Of 836 presumptive MDR-TB patients referred from 398 peripheral microscopy centres, 161 MDR-TB patients were diagnosed
Poor record-keeping and unreliable upkeep of presumptive MDR-TB patient databases were identified as challenges at the peripheral microscopy centres

Summary

Introduction

Despite progress in the detection of Multi-Drug Resistant/Rifampicin Resistant Tuberculosis (MDR/RR-TB) cases, major diagnostic gaps remain: 55% of reported TB patients estimated to have MDR-TB were not detected in 2013 [1]. Identification of MDR-TB cases and prompt initiation of treatment are crucial to prevent the transmission of disease and reduce related high morbidity and mortality [2]. Studies worldwide in the past have documented pre-diagnostic (21%-90%) and pre-treatment attrition in the pathway of presumptive MDR-TB patients [3,4,5,6,7,8,9]. Though introduction of molecular diagnostic techniques has resulted in a decrease in laboratory Turn Around Time (TAT), operational issues still remain a major concern. Bangladesh is one of the 27 high burden countries for MDR-TB [1]. In 2013, there were 2100 (1.4%) and 2600 (29%) estimated MDR-TB cases among the notified pulmonary new and re-treatment TB cases respectively

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Conclusion