Extension of the intensive phase reduces unfavourable outcomes with the 8-month thioacetazone regimen.

SETTING: Damien Foundation tuberculosis (TB) control projects in Bangladesh. OBJECTIVE: To assess the effectiveness of a 1-month extension of the intensive phase for smear-positives at 2 months of an 8-month regimen with a continuation phase consisting of isoniazid (INH) and thioacetazone (Th). DESIGN: A prospective study of two cohorts of newly registered smear-positive cases, with extension of the intensive phase for the control cohort, but not for the study cohort. Culture and drug susceptibility testing (DST) of smear-defined failures and relapses and of random samples of new cases. RESULTS: Among 8230 study patients (86.7% 2-month conversion) and 7206 controls (83.4% conversion), smear-defined failure or relapse outcome was 3.0% for 2-month smear-negatives vs. 3.1% for 2-month smear-positives with extension (non-significant, NS), and 8.2% for 2-month smear-positives with no extension (P < 0.00001). Culture-confirmed failure and relapse reached 1.9% in 2-month smear-negatives and 1.6% (NS) in 2-month smear-positives with vs. 3.7% (P < 0.001) in 2-month smear-positives with no extension. The relative risk (RR) of non-extension in 2-month smear-positives was 2.4 (cultures) to 2.7 (smears). The same RR and borderline significance was found for non-extension of patients with pan-susceptible strains. CONCLUSIONS: Extension of the intensive phase considerably reduces failures and relapses with a weaker regimen in patients smear-positive at 2 months. Its effectiveness may vary with extent of initial drug resistance vs. power of the regimen.

Turning liabilities into resources: informal village doctors and tuberculosis control in Bangladesh.

In 1998, the Damien Foundation Bangladesh invited semi-qualified, private "gram dakter" (Bangla for "village doctors") to participate in tuberculosis (TB) programmes in a population of 26 million people in rural Bangladesh. The organization trained 12 525 village doctors to not only refer suspected TB cases for free diagnosis but also to provide directly observed treatment (DOT) free of charge. Source of referral and place of DOT was recorded as part of the standardized TB recording and reporting system, which enabled us to quantify the contribution of village doctors to case detection rates and also allowed disaggregated cohort analysis of treatment outcome. During 2002 and 2003, 11% of all TB cases with positive sputum smears in the study area had been referred by village doctors; the rate of positive tests in patients referred by village doctors was 14.4%. 18 792 patients received DOT from village doctors, accounting for between 20% and 45% of patients on treatment during the 1998-2003 period. The treatment success rate was about 90% throughout the period. Urine samples taken during random checks of treatment compliance were positive for isoniazid in 98% of patients treated by village doctors. Within the framework of Public-Private Mix DOTS, services provided by semi-qualified private health care providers are a feasible and effective way to improve access to affordable high quality TB treatment in poor rural populations. The large informal health workforce that exists in resource poor countries can be used to achieve public health goals. Involvement of village doctors in TB control has now become national policy in Bangladesh.

Current status of leprosy and leprosy control in Bangladesh: an ongoing collaboration.

Elimination of leprosy as a public health problem, defined by a registered prevalence of less than one case per 10,000 population, was achieved by Bangladesh in 1998, and steady reduction in prevalence is ongoing. It is less certain whether a sustained reduction in case detection is occurring, with little overall change in some longstanding programme areas, though the overall annual new case detection rate has fallen by over one-third between 1996 and 2004, from 9.8 to 6.1 per 100,000. Concerns about 'hidden' cases have been raised in Bangladesh as elsewhere, though the National Leprosy Elimination Campaign of 1999 detected relatively fewer new cases than in other countries, and mainly in low endemic areas. Investigation into the correct diagnosis of leprosy and recording and reporting practices has not suggested high levels of over-diagnosis or 'over-registration'. Both before and since achievement of the elimination target at national level, the collaboration of Non-Governmental Organizations with the national Leprosy Elimination Program has been considerable. NGOs now support ongoing leprosy control efforts in rural and urban populations, moderate to high endemic for leprosy, amounting to 50% of the entire population, and NGO staff look after 75% of all new cases in Bangladesh. This close collaboration has highlighted the potential for large-scale partnership in disease control, and has expanded to extensive partnership in tuberculosis control, which will hopefully enhance cost-effectiveness and quality of both programmes. Further challenges remain in the area of urban leprosy control, where leprosy case finding represents 30% of the whole country, but public health infrastructure and community organization is weakest. Sustaining of leprosy services in the long term is a significant concern, and new modes of collaboration, with a more technical, supportive role for NGOs in some areas is being piloted.

Gender differences in tuberculosis: a prevalence survey done in Bangladesh.

SETTING: Bangladesh national tuberculosis control programme districts supported by the Damien Foundation (population 18 million). OBJECTIVE: To determine whether the observed gender difference is epidemiologically true or whether it is due to accessibility barriers for women. DESIGN: Two-stage random sampling population survey. People were interviewed by teams composed of one male and one female volunteer about the presence of symptoms suggestive of tuberculosis. One early morning sputum specimen of all thus identified tuberculosis suspects was examined by Ziehl-Neelsen technique. RESULTS: A total of 266189 people were surveyed, among whom 223 936 (84.1%) could be interviewed. This led to the identification of 7001 tuberculosis suspects (2406 females and 4595 males) and 64 confirmed TB cases (16 females and 48 males). The female/male ratio (0.33:1) of cases found during the survey was not higher than that observed through routine diagnosis (0.42:1). The routine case-notification rate of sputum-positive cases during 2000 was about twice the rate observed during the survey (44.3 vs. 24.0 per 100 000 population). CONCLUSIONS: The gender difference observed in routine tuberculosis diagnosis is real, and is not due to lesser accessibility of women to the health services. The routine notification rate compares favourably with the detection of previously unknown cases found during the survey.