Multidrug resistant tuberculosis (MDR-TB) in community setting of Bangladesh

Background: Bangladesh is one of the high burden countries for tuberculosis (TB) as well as for multi-drug resistant tuberculosis (MDR-TB). Research projects presented in this thesis addressed the following areas: risk factors for development of MDR-TB; factors related to previous tuberculosis treatment of MDR-TB patients; delays in treatment of drug sensitive tuberculosis patients; and the health system delay in the treatment of MDR-TB patients, in Bangladesh. Method: This thesis by publication consists of four papers. A case control study of 250 MDR-TB patients as cases and 750 drug sensitive TB patients as controls was conducted to determine the risk factors of MDR-TB in Bangladesh. A total 293 patients of the same dataset, who had history of previous tuberculosis treatment, were included in the second study to identify the factors related to previous tuberculosis treatment. MDR-TB patients who were diagnosed using the rapid diagnostic tests (n=207), were included in our fourth study, to determine the health system delay in MDR-TB treatment. We had conducted another cross sectional study (n=7280) to determine the delay in drug sensitive TB patient which has also been included in this thesis. Key findings: Our first study suggests that previous tuberculosis treatment is the major contributing factor to MDR-TB (OR 716.6, 95% CI 282.1-1820.8). Other factors found to be associated with MDR-TB are age group “18-25” (OR 1.8, CI 1.1-2.9) and “26-45” (OR 1.7, CI 1.1-2.7), compared to the age-group “ >45 years”; patient’s education up to secondary level (OR 1.9, CI 1.32.8), as opposed to the “no education” group; service and business as occupation (OR 2.9, CI 1.3-6.4; OR 3.7, CI 1.6-8.7, respectively); smoking history (OR 1.6, CI 0.99-2.5); and type 2 diabetes (OR 2.6 CI 1.5-4.3). Incomplete treatment (4.3; 95% CI 1.7-10.6), hospitalization for tuberculosis treatment (OR 16.9; CI 1.8-156.2), and adverse reaction (OR 8.2; 95% CI 3.2-20.7), are the factors related to previous tuberculosis treatment most likely to result in MDR-TB. Drug sensitive TB patients, who are seeking care from informal practitioners access care more promptly, but experience prolonged delay in initiating treatment, compared to those visiting qualified practitioners (p<0.05). Health system delay (time between visiting a provider and start of treatment) of MDR-TB patient was associated with the visit to private practitioners for first consultation, compared to visiting a DOTS centre (mean difference (days): 37.7; 95%; CI 15.0-60.4.1; p 0.003). Introduction of rapid diagnostic methods for MDR-TB has reduced the diagnosis time although some degree of delay was present in treatment initiation (median 5 and 10 days, respectively). Conclusion and recommendation: National Tuberculosis programmes should address identified risk factors in MDR-TB control strategy including previous tuberculosis treatment. Socio-demographic groups such as specific age-groups and people with some levels of education, who were associated with development of MDR-TB, could be addressed by the national TB control programme, through effective communication approach in preventing drug resistance. The integration of MDR-TB control activities with diabetes and tobacco control; engaging the private practitioners in MDR-TB control; and continued involvement of informal practitioners for early referral for diagnosis and treatment of TB, are needed in Bangladesh.