Strategies to increase TB case detection in rural Bangladesh focusing on inequities and delays in care-seeking

Research Overview

TRAction is currently funding a research study in Bangladesh exploring the effectiveness of multiple case detection strategies for Tuberculosis (TB) in rural Bangladesh. This cluster randomized controlled trial tests active and semi-active case detection strategies comparing it to the standard of care (passive case detection), and any potential impact on increasing TB case detection in marginalized populations.

Bangladesh is one of the 22 countries of the world with high burden of TB, with a prevalence of 411 cases per 100,000 population. A nationally representative survey conducted in 2009 revealed that the prevalence of TB is 10 times higher among the lowest wealth quintile, compared to the highest; and greater in rural areas compared to urban areas. Current TB measures have proven to be more successful in detecting TB cases in the middle and upper wealth quintiles, while poorer populations have fallen through the gaps in the system.

This is partially attributable to the passive nature of the country’s case detection mechanism – Case finding is reliant on patient awareness, accessibility and availability of health services. The approach has seen detection rates plateau at 60 percent in poorer populations, compared to 90 percent in higher wealth quintiles. Overall, studies from Bangladesh show that delays in TB diagnosis are unacceptably long (mean of 8 weeks), and that older age, rural residency and perceived high stigma are significantly associated with delay in TB diagnosis and treatment. Gender is also a factor, as case detection rates have been found to be consistently higher for men.

Study Location

Bangladesh: Chakaria Upazila

Research Objectives

1. Increase smear positive pulmonary TB case detection in populations 15 years or older, under the coverage of the National TB Control Program (NTP)
2. Document reduction in delay in initiation of care
3. Address inequities in TB service utilization under the NTP

Study Approach

1. Active Case Detection: House to house symptom screening; suspect identification, referral and follow up via trained community health workers; and community mobilization
2. Semi-active Case Detection: Contact tracing of known contacts of all known TB cases; screening via community cough camps; referral; and community mobilization
3. Capacity building of Village Doctors to increase effectiveness of private sector TB management

Key Findings

Higher numbers of new smear-positive (NSP) and all types of cases were identified under cough camp strategy. The increase in case notification rate (CNR) of NSP and all types of cases was also higher in cough camp areas than in other areas. Higher numbers of female cases were identified than the male cases (M:F 0.8:1) in the cough camp areas. About one-half of the cases detected in all the areas were above 45 years of age, had no education, and belonged to the middle and lower economic class of the population. Cough camp approach was found to be more effective and suitable than any others in improving the case detection rate in the rural area of Bangladesh

Lessons Learned

The cough camp strategy resulted in an increased case detection rate for all types of cases than the other modes of case detection. More female than male cases were identified in cough camp areas, although similar numbers of TB suspects among males and females were screened and tested. This indicates the possibility of under-detection in many cases, particularly female cases under routine programme. The NTP should expand its case detection strategy by including the cough camp approach, in addition to its ongoing approaches.

Active case and Semi-active case finding lead to higher detection of TB cases overall, and especially among the poor population. The labor intensive nature of Active case finding is problematic when considering this approach as an alternative to the standard of care. TB cough camps at suitable places & contact tracing under supportive supervision & effective monitoring can increase case detection.  Village doctor services are not perceived to be valuable by the community; innovative approaches are needed to successfully integrate village doctors​. Unfortunately, lack of knowledge and stigma remain strong barriers to care-seeking.

Research into Action

The results of this study is directly informative to the implementing partners of the National Tuberculosis Program, and will secure better targeting and case-detection for the most vulnerable and marginalized population groups in Bangladesh. 

Implemented by 

International Centre for Diarrheal Disease Research (icddr,b)

Principle Investigator: Dr. Shahed Hossain

Project Status