Roundtable on

Lung Heath and Tuberculosis Control:

Present Situation and Future Direction

May 14 2012
Venue: BRAC Centre, 75 Mohakhali, Dhaka-1212
Organised by: New Age and BRAC

Nurul Kabir
Editor, New Age
We have arranged the roundtable discussion on the situation of tuberculosis in relation with lung health in our country, how we can control spreading of the disease and how to improve the situation so that it does not require control in the future. Though treatment of the disease was invented many years ago and a significant portion of the population is aware of the disease, we need to find out why we are yet to successfully eliminate the disease from Bangladesh. It is important, to evaluate where the challenge is. We are seeing some anxiety among people working in this particular sector. I think it is much more essential to think about it instead of being anxious. We are arranging this discussion to proceed with thinking on the issue, to find out how we can play a role and which sectors need intervention.
TB has a literal connection with our environment, economy and disparity, and finally the state decides whom it will provide health support to. So health is not only a health issue, rather it is a political issue as well, and there is the subject of the political economy of health.
The world’s medicine business is connected with what kind of medicine will be used, preventive medicine or curative medicine, which is also a political issue. The medicine business is the third largest business after arms and food.
If the society continues to be depoliticised and if we look at these issues as isolated ones, we will not be able to address any problems. We will fail to set priorities and there lies the point of coordination among health, education, media and other sectors. In order to stop all kinds of anti-people policies and to expedite good work, we need to build up a concerted resistance, and for that joint initiatives of public health and media would be necessary. 

Dr Md Ashaque Husain
Director MBDC and Line Director TB-leprosy
National TB Control Programme
It is correct that physicians have less interest regarding communication. I will not disagree with all allegations, but again I want to add that doctors have sympathy for their patients.
National TB Control Programme is receiving large donor funding and we try to keep transparency during the implementation of the programme. Donor’s first priority is to ensure quality service—in diagnosis, treatment, drugs and others.
According to the draft report, which had been sent to WHO for more details and finalisation, the percentage of multi drug resistance, in new cases,  is less than many other countries. The percentage is about only 1.5 percent, which is lower than the 2.1 percent in the earlier report.
DOTS is a globally accepted strategy. It is true that many patients stay out of TB detection due to microscopic tests. In place of conventional microscopes we are going to introduce LED microscope to 1050 peripheral labs across the country. 30/40 LED microscopes have already been distributed and another 200 will be distributed very soon. As a result, the chances of non detection would be reduced significantly.
DOTS programme, now focusing on every form of TB, points out that a good number of sputum negative patients did not get medicine from DOTS centres. We will also ensure adequate medicine, technology and manpower at the upazila level to detect childhood TB. We want to take our services to the doorstep of the people.
We had made drugs for TB treatment available free of cost. Even in 1990, pharmaceutical companies used to produce anti tuberculosis drugs. But now only one pharmaceutical produces anti tuberculosis drug. We had set a target that by 2050 TB will be eliminated in Bangladesh.  For elimination of TB all out cooperation and involvement from all sectors is needed.

Dr Mojibur Rahman
National Programme Consultant
Nat’l Tuberculosis Control Programme
In Bangladesh, 20 per cent of the adult population (above 40 yrs) suffers from chronic obstructive pulmonary diseases, 6.2 per cent of the population above 15 years suffer from asthma and 70 per cent of total male cancer victims suffer from lung cancer. Twelve million people across the world are suffering from tuberculosis. In 2010, 8.8 million new cases were recorded and 3.3 million of them were women. The number of people who died of only tuberculosis was 1.1 million and another 0.35 million died from tuberculosis coupled with HIV AIDS. 
The national tuberculosis programme has achieved its goal of detecting cases 70 per cent, treatment success of 85 per cent, and it was now working towards achieving MDGs like halving tuberculosis mortality and prevalence rate, halting and reversing tuberculosis incidence by 2015, and achieving universal access to high quality care for all people with tuberculosis. There are also plans to carry out an external review of the activities in 2012, carrying out a nation-wide representative TB prevalence survey in 2013 and a nation-wide representative HIV prevalence survey among TB patients in 2014, setting up regional TB reference laboratory (RTRL) in Khulna, Sylhet and Barisal, repeating the nationwide drug resistance survey in 2015 and introducing Practical Approach to Lung Health.

Dr Kaosar Afsana
Director, BRAC Heath Programme
Tuberculosis remains as a major public health problem in Bangladesh. Although, we are on track for the millennium development goal 6, it does not mean that burden of TB death and disease has been declined. The commitment to control tuberculosis is immense at global and national levels. We are working with a great commitment at community level. The problem arises when long period therapy leads to defaulter and eventual multi-drug resistance. The treatment of tuberculosis is not a simplistic therapy - a treatment for six months. It is not easily acceptable by the patients to continue medicine intake regularly for a long six-month. We often forget to take pills of a seven-day antibiotic course. Hence, when a patient misses to take medicine, resistance may develop to that particular antibiotic. As a result, when the bacteria infect others, a patient also becomes resistant to this drug. Tuberculosis management, diagnosis, treatment and follow-up are thus interrelated.  We are a successful country in tuberculosis control, and our Bangladesh model is followed by many countries especially community health worker providing DOTS. We should be aware of our success and here, media can play a great role in creating awareness among people.
Urban health is nobody’s ‘child’ in this country as there lacks ownership in the Ministry of Local Government and the Ministry of Health has no business in this particular area. Having this situation as an orphan, urban health issues are completely ignored. Lung health is emerging as a prime public health concern. Seventy per cent of the people suffering from cancer actually had lung cancer. Visibility of lung health along with its contribution to burden of disease is crucial to make the country and people aware of the problem and to take necessary actions on time.  

Dr K Zaman
Scientist/Epidemiologist
Public Health Sciences Division, ICDDR,B
I begin with a good news that we have established a TB research group at ICDDR,B which will engaged only in TB researches. I should say tuberculosis control programme in Bangladesh is a success story as we did in oral rehydration saline, family planning, and expanded programme immunisation. We at ICDDR,B in collaboration with NTP, BRAC, Damien Foundation and other partners did a research recently which has already been published and it found sputum +ve TB 79 per 100,000 population only. It was 318 in 1966, 870 in 1986-87. But in the research we found that prevalence of TB among poor and little-educated males was much higher. The middle-class uses the DOTS centre much more than others, not the poor. Now the research we need to carry out next is multi-drug resistant TB. Treating MDR TB is so tough. It costs $ 800 to $1000 for MDR TB treatment in our country where DOTS treatment costs only $30. Abroad it costs $ 100,000 to $ 200,000. I think we should conduct research on MDR TB treatment in next few years.

Dr Fatema Jannat
Country Director, URC
University Research co, LLC
There are many things to say on gender issue. But if I want to focus on why females are getting infected by TB lesser than men, it is actually for discrimination and gap in symptom recognition. There is a gap in access to health services. We did a survey from TB Care II on why there was no early day detection among women and why female case detection rate was low. It revealed issues of gender discrimination and some other social disparity. I strongly want to say that we have lots to do. We identify women among vulnerable groups. If we can address it, the gender issue will be possibly covered. If we want to block TB transmission, early case detection is most essential. Lung health and TB are two broad areas in terms of public health and we need to opt for a specific approach. Diagnosis is most important. We at TB Care II have introduces LED microscope which can detect cases at 200 times accuracy and we have also installed GeneXpert machines and initiated cPMDT (community based programmatic management of drug resistant TB) and we think cPMDT will bring a great change in MDR TB management.

Prof Md Mostafizur Rahman
Former Director, NIDCH
Vice President, Bangladesh Lung Foundation
MDR (multidrug resistant) TB is very tough to treat. Usually we can treat patients with six months treatment. But if two of the major drugs gets resistant, it becomes tough to treat an requires at least 18-24 months and the costs goes high and its cure rate is too little, 40-50 per cent internationally. We were lucky that it was 70 per cent at our chest disease hospital.
MDR TB is a man-made phenomenon. It is created by us, the health service providers, physicians and patients. There remained a problem in drug regime. After taking drug for two months a patient discontinued taking drugs and it is the major cause of MDR TB. If we do not set them an effective regime, the drug will not work. Problems also arise if we do not set the dosage based on height and weight of the patient. So we have to guard against creating MDR TB. The earlier MDR could be diagnosed, the more benefitting for the nation. Because the patients need to be monitored till the patient cured. In case of bird flu we can cull birds but we cannot kill patients. I would like to draw attention to the cases of drug reaction specially TB patients with renal failure or other such combinations. 

Prof Mahmudur Rahman      
Coordinator
Dhaka Community Hospital Trust
Tuberculosis prevailed in Great Britain too and people died there as people die here in Bangladesh till 1950s. It was not drugs or today’s DOTS therapy. Rather it was the advancement of their living standard. Their income grew, housing system developed and nutrition level increased. We know the history. Till now 22-40 per cent of the world’s population are annually infected with micro-bacterium tuberculosis.
Besides, we now have fast industrialisation that causes pollution. And pollution too one of the factors that awakes latent TB specially industries like mining. We need to look after where the latent TB can be active. I am hopeful that we one day will be free from TB but it is a very narrow possibility. It existed 10,000 years ago, still exists and will remain after another 10,000 years. But it can be controlled.
Another problem in treatment is we remain confined in two to four drugs. If a patient is resistant to two of the drugs, he will become resistant to the third one very quickly.
In a country like ours, There is no research in the sector that what’s the percentage that can spread TB in the Diabetic Patient. TB and Diabetis may be another research area. Till date we do not carry out case reporting properly. It is a major problem. Even in major hospitals case reporting is not carried out. 

Dr Kumkum Pervin
Manager Medical Affairs
Sanofi-Aventis Bangladesh Ltd
Experts often argues that sometime as a result of taking fixed dose combination drugs by TB patients creates some complexities due to inter reaction. So I can add that if government wants single drug can be revived.
As the round table is also arranged to discuss lung health diseases I want to add that to prevent lung diseases like pneumonia people specially elderly groups can take pneumococcal vaccine.

Dr Masudur Rahman
Portfolio Manager 
Novartis (Bangladesh) Limited
First I want say that Novartis was created in 1996 through the merger of Ciba-Geigy and Sandoz, two companies with a rich and diverse corporate history. And Ciba-Geigy had decade long relation with TB diseases. When Rifampicin was invented in late 1950, scenario of TB control had changed a lot, across the globe.
Novartis is only pharmaceutical in Bangladesh producing anti TB drug. We export our anti TB drug to the al least 25 countries. We dominate the market of TB drugs in Indonesia, Thailand and Brazil, but it government of Bangladesh do not purchase our anti TB drug for its programmes.
Here I can share that Novartis Institute for Tropical Diseases is working hard to reduce the tenure of the TB treatment and we are hopeful that treatment of TB would be reduced to two or four months comparing to current six months.
In Bangladesh we are focusing on open TB cases but close TB cases also needed attention. In our country there are no discussions about extra pulmonary TB, even DOTS centres were not concern about extra pulmonary TB.

Prof Mesbah Kamal
Department of History
Dhaka University
TB is not only a medical problem it had strong connection with social issue. This makes me more concerned. I do not know whether the people vulnerable to TB have been identified or not. Furthermore, wealth disparity has widened since independence and the gap is widening everyday. And if this disparity remains we will never be able to solve the problem of TB. We need to address the issue of disparity to control TB in Bangladesh.
We also came to know that the poor are not using the benefits of DOTS, but they are the most vulnerable and prone to TB. We also came to know that child TB detection was slow. It is also important to detect child TB, as about 40 per cent of the total population are children. Focused budget is needed for TB control.
TB has strong links with tobacco. But in Bangladesh, although the price of daily essentials has become out of reach for people, price of cigarettes did not increase significantly. In Bangladesh cigarettes are cheaper than any other country. Here, you will get a packet of cigarette at Tk 11. During the last seven or eight years, only one per cent tax was imposed. And the overall tax was less than any other South Asian country, as Nepal imposes72 percent tax, while India imposed 58 per cent. In Bangladesh tax was about 49 percent.
If the disparities between the wealthy and poor, male and female are not addressed, these issues cannot be addressed either.

Afsan Chowdhury
Senior Advisor (Communications)
BRAC Centre  
I am in touch with the health sector on different issues for last 25 years, and the way physicians talk in this programme is not communicative. I want to tell physicians that you need to communicate with people more. As nowadays patients frighten doctors.
I will request that NTP and BRAC should take the initiative to publish a guideline, having detailed information about TB, to understand the disease. As I understand, nowadays physicians do not have concerns about patients. TB management is far from their sight. The poor are more distant from their sight. Physicians should keep in mind that all are not doctors and they should communicate with patients more. 
While I was editing a WHO book ‘Stopping a Killer’, published from New Delhi, I found DOTS having success across the globe and general people getting the benefit. Please provide some attention to poor TB patients. Like Mesbah, I also want to say that to address TB we need to reduce disparity in the society. For that we will need joint public-private initiatives, without which no fundamental change would take place in TB control. 

Dr Md Abdus Shakur Khan
Assistant Professor
National Asthma Centre, NIDCH
As a physician I did not like the keynote paper. We are saying that we are now detecting 70 percent of TB patients. But everybody knows that there are problems with the recording system. In the keynote it was said that women might have a special immunity and that is why incidences of TB in women was less. I beg to differ with that information. There are many positive sides of DOTS. But what DOTS is providing, who will come here, how s/he will get benefit from it, are all these concerns being addressed? There is some positive work of physicians that should also be discussed, in ORS, EPI, which have been successful in reducing child and maternal death rate. Many people in Bangladesh are living below the poverty line. Awareness regarding health issues is less among these people as formal and informal education does not provide health education.

Nawazish Ali Khan
Adviser (Programs)
ATN Bangla Ltd.
Both doctors and media work for the people. Practical education was absent in the country. As a former government employee, and now in the private sector, I can say that there is a problem with physicians, journalists, politicians and others. We have to seek ways for solving these problems.
Due to the failure of family planning, the population is increasing at an alarming rate and now the population stands at 16 crore. Who will provide food, shelter, health, education and other benefits to this huge number of people? It has become impossible to meet their demands. 
To address the problems I feel education can play a vital role. Media should be more aggressive in addressing health issues, including TB. Alongside health and information, education regarding TB in the family is also important. People need information. As they come to have information they will be conscious and take the benefit of every programme.  
One more thing is that discussions like today should be arranged regularly, because through discussion with different opinions we can come towards a solution. Physicians are claiming that they are successful in providing services. But there are great failures as well, like in all other sectors.  
 
Fahim Munaim
Chief Executive Officer
Maasranga Television Centre
This keynote paper focuses on detection and cure of TB. But the media is not included in any programme. If introduced, the media can play a vital role. It can disseminate all information about TB to the people. I request you to introduce media in the programmes as we can hammer out solution to these issues together. Media will come forward to combat TB. Along with others factor, media played a vital role in eradicating malaria and polio.
Call all media to discuss about TB and I believe they will come forward as they also have some responsibility. Utilize media to disseminate information regarding TB to people. If you want to be pro people you need to address pro people concerns like health. I liked Mesbah’s discussion about disparity and budget allocations, which is a really important thing for combating TB.

Saifuddin Ahmed
Executive Director
WBB Trust
We need to have education about how to live. Tobacco is related with TB control. We should take steps to control TB. For this tobacco control laws need to be amended for better enforcement of tobacco control.
In this discussion we focused on cure of the TB and others things related to aftermath of infection of TB. But we should focus on how we can prevent this disease.
We know we have limitations, we have a lack of education, but we have to take the initiative to prevent TB.   

Dr Md Zakir Hossain Sarker
Consultant (Pulmonology)
LABAID Specialised Hospital
Sometimes confusion arises regarding TB case detection. Although NTP is successful, MDR patients are increasing day by day and MDR TB is dangerous. We are talking about success of DOTS. But how friendly are these DOTS centres towards patients? In many occasions, DOTS centres advise on some unnecessary diagnosis. Do DOTS centres hold any authority to advise on diagnosis? NTP should take care of these complaints.

Syed Masud Ahmed 
Senior Research Coordinator
BRAC Research and Evaluation Division
Currently both print and electronic media are more focused on curative measures; there is lack of media concentration upon preventive aspect of diseases. Many IEC materials/messages have already been developed to aware the people about tuberculosis. Recently a study has been conducted by BRAC research and evaluation department to evaluate the knowledge of the people regarding TB in hard to reach area including ethnic minority. Another study from BRAC RED revealed that, worse economic conditions, stigma, fear of marital problems of the unmarried girl due to TB acted as barriers to improve TB case detection among female .
Smoking is one of the major risk factors for TB, among the smoker.

Dr Jobayer Chisti
Associate Scientist (CNFS) and Clinical Lead
ARI Ward, Dhaka Hospital, ICDDR,B
We are working with tuberculosis for long at ICDDR,B. As a paediatrician and paediatric pulmonologist, I am working on childhood TB for past two years. Here is Zaman Bhai, we both work in a team. Our observation is very little work has been done on childhood TB, not only in Bangladesh, rather across the globe the situation is the same. So we wanted to proceed in childhood TB as we could do in the case of adult TB.
At the Dhaka hospital of ICDDR,B where we treat poorest of the poor, we are trying to conduct a study on severely malnourished children suffering from acute pneumonia. No such study has taken place in Bangladesh yet, though little is done in South Africa or Malawi. For past two years, we found that children coming with two-week old cough carry tuberculosis. And the rate is so high. Even the rate of TB presence was higher than bacteria isolation of pneumonia. We are about to finish our studies and will disseminate in the next national tuberculosis day programme. We need to work on how we can resist child tuberculosis. And paediatricians and paediatric pulmonologists should work with a wider spectrum.

Prof Mirza Md Hiron
President
Chest and Heart Association of Bangladesh
Undoubtedly the scenario of detecting TB has improved in Bangladesh, but there was no improvement in terms of absolute numbers. In the past we had about 300,000 TB patients and about 60000 deaths in a year. Still now 303,000 are getting TB and 65,000 die per year.
It would be difficult to achieve the Millennium Development Goal’s target to halve TB mortality and prevalence by 2015 if a comprehensive strategy is not adopted.
Another thing that is important is that National TB Control Programme should be included in the medical curriculum, to provide a complete idea of TB control, recording and others.
According to WHO, in 2010 there were 14,553 MDR patients, among who 12,552 were primary and 2,021 were pre-treatment MDR patients in Bangladesh. In NIDCH, in association with NTP and WHO, 700 patients will get treatment in five years under DOTS plus project. 350 have already received treatment. Damian Foundation was providing treatment to another 700 patients. What fate is waiting for the rest? The government should take immediate steps to provide treatment to these MDR patients.

Prof Md Ruhul Amin
Paediatric Pulmonology
BICH, Dhaka Shishu Hospital
Of the total population 45 percent are under the age of 15. TB detection rate from this group in Bangladesh was only 3 percent, while it was about 9 percent in other countries. National TB detection rate was about 70 percent which means child TB was not detected properly. Consciousness about child nutrition should be raised in Bangladesh as it has a strong connection with child TB. Breast feeding is another concern, as it reduces chances of TB infection. I want to emphasize on the referral system of TB patients as well as other diseases.
TB control is very much possible in Bangladesh. We have almost eradicated polio, malaria, diphtheria and several other diseases from our society.